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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607362
Report Date: 04/14/2026
Date Signed: 04/14/2026 02:58:58 PM

Document Has Been Signed on 04/14/2026 02:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANNABELLE'S COTTAGE IIFACILITY NUMBER:
197607362
ADMINISTRATOR/
DIRECTOR:		DAISY HAILEYFACILITY TYPE:
740
ADDRESS:6218 W. AVENUE J-12TELEPHONE:
(661) 579-9522
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 6DATE:
04/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Maria Ana Rodriguez - Caregiver/DesigneeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by the Caregiver/Designee, Maria Ana Rodriguez. LPA signed in and checked their temperature on a thermometer affixed to the wall. In the facility LPA observed two (2) caregivers and six (6) residents. The Caregiver/Designee informed the Licensee, Anne Gregorio that LPA was at the facility. The administrator, Daisy Hailey and the licensee will not be able to meet with LPA today. LPA explained the reason for the visit.

At 9:05 AM, LPA initiated a physical plant tour of the facility inside and out and the following was observed.

LPA observed appropriate postings at the entry of the facility which included a facility sketch and LIC610E. The facility has an open concept space with the living room, dining area and kitchen. The areas were clean, clear of clutter and were properly furnished. The dining area had a table and chairs that sit the capacity of the facility. Living area had a television and seating for the capacity of the facility. LPA observed two carbon monoxide detector one by the entry and another in the hallway by bedroom #3 and #4. They were tested and observed functioning properly. The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed knives locked in a kitchen drawer. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food. LPA observed one (1) fire extinguisher fully charged with a last serviced date of 05/08/2025. LPA inspected five (5) out of five (5) resident bedrooms. One (1) out of the five (5) bedrooms is a shared bedroom. LPA observed each resident room to be properly furnished with a bed, a night stand, one chair, bedding, sufficient lighting and storage. LPA opened exterior doors in all resident bedrooms and observed the auditory alarms were functional. (Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362
VISIT DATE: 04/14/2026
NARRATIVE
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(Continued from LIC809) LPA observed the doorways to room #3 with gaps on the flooring. The rugs used to cover the doorway to room #4 were observed lifted at the corners. The facility has three (3) bathrooms. One (1) bathroom is in the shared bedroom. Hot water temperature in two (2) bathrooms was measured, temperature was between 117°F and 118 °F, within regulation. LPA observed the bathrooms to be clean and properly supplied with toilet paper and hand soap. LPA also observed grab bars and non slip shower mats. The laundry room leading to the garage and staff bedrooms is kept locked and inaccessible to residents. Detergents are kept locked in the laundry room. In the backyard, LPA observed a covered patio and outdoor furniture for resident use. Passageways were clear of obstructions and there were no bodies of water observed.

At 10:25 AM, LPA observed a caregiver test smoke detectors in the hallway, in bedroom #1, #3, #4 and #5. Detectors were observed to be functioning properly. At 10:32 AM LPA reviewed the register of facility residents (LIC9020) and the Personnel Report (LIC500). According to the Caregiver/Designee the LIC500 needed to be updated. LPA reviewed the Emergency Disaster Plan (LIC610E), Liability Insurance Certification and outdated emergency disaster drills. LPA was not provided documentation that an emergency disaster drill had been conducted in the last quarter.

At 10:49 AM, LPA conducted a file review of six (6) of six (6) resident records to ensure compliance with licensing forms. Review of Resident#1 (R1's) Physician's Report (LIC602) notes their ambulatory status as nonambulatory. Review of the facility's approved Fire Inspection (STD850) and facility sketch shows Room #1 where R1 is residing is cleared for an ambulatory resident only. Review of Resident#2 (R2's) Pre-placement notes their ambulatory status as nonambulatory and Room #2 where R2 is residing is cleared for an ambulatory resident only. Facility had submitted a request to update ambulatory status in 2019 but LPA did not see evidence or was provided evidence from the licensee that it was processed. R2 has an admission date of 02/15/2026 without a medical assessment on record. Facility has a Hospice waiver for three (3) but currently based on resident records and staff interview four (4) residents are receiving Hospice services for a terminal illness. LPA reviewed medication and medication records for proper documentation. LPA conducted a file review of two (2) staff records to ensure compliance with licensing forms. Two (2) out two (2) staff have expired First Aid/CPR certification.

Exit interview conducted. Deficiencies cited (refer to LIC809-D). Appeal rights explained and provided. Copy of report provided to the designee.
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 04/14/2026 02:58 PM - It Cannot Be Edited


Created By: Evelin Rios On 04/14/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 6 residents identified as non ambulatory residing in ambulatory only bedrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2026
Plan of Correction
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The licensee will submit LIC 200 and facility sketch identifying which bedrooms they would like to be cleared for non ambulatory by POC due date. Licensee was informed if fire clearance is not approved arrangements need to be made to transfer resident to a proper placement.
Type A
Section Cited
CCR
87632(a)
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the above section by failing to increase their hospice care waiver from 3 to 4 and accepted or retained 4 terminally ill residents, which poses an immediate health, safety and personal rights risk to residents in care.
POC Due Date: 04/15/2026
Plan of Correction
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Licensee will submit a Hospice waiver increase request to the department by POC date. If not approved facility will need to make arrangements to transfer resident to appropriate facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 04/14/2026 02:58 PM - It Cannot Be Edited


Created By: Evelin Rios On 04/14/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 caregivers at the facility had expired first aid and CPR certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Licensee agreed to provide copies of active First aid / CPR for the caregivers identified as having an expired certification to the department by POC due date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have a completed medical assessment or Physician's Report (LIC602) on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Licensee agreed to provide a copy of R2's complete Medical Assessment / Physician's Report (LIC602) to the department by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 04/14/2026 02:58 PM - It Cannot Be Edited


Created By: Evelin Rios On 04/14/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 6 residents (R4, R5 and R6) that have been residing in the facility for over a year do not have a reappraisal conducted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Licensee agreed to provide a copy of R4, R5 and R6's completed reappraisal to the department by POC due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents does not have an admission agreement signed by their responsible person which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Licensee agreed to provide a signed admission agreement for R1 to the department by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 04/14/2026 02:58 PM - It Cannot Be Edited


Created By: Evelin Rios On 04/14/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in not documenting quarterly drills conducted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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2
3
4
Licensee agreed to conducted emergency disaster drill and provide documentation drill was completed by all shifts to the department by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
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