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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 06/19/2024
Date Signed: 06/19/2024 08:15:04 PM


Document Has Been Signed on 06/19/2024 08:15 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ANNABELLE'S COTTAGEFACILITY NUMBER:
197604938
ADMINISTRATOR:DAISY HAILEYFACILITY TYPE:
740
ADDRESS:3732 VITRINA LANETELEPHONE:
(661) 947-0052
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:5CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the staff member. Staff member called the Administrator who stated would not be able to come to the facility until 3:00 pm. At 10:20 am, LPA Spaeth spoke to the licensee, Anne Gregorio who stated will be reporting to the facility. LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for five (5) non-ambulatory residents of which one may be bedridden. LPA confirmed there are four residents in the facility.

LPA Spaeth observed another person living in the facility. The staff member confirmed the other person living there is a relative of the staff member. However, LPA observed the relative's name was not listed on the Facility Personnel Report Summary. LPA Spaeth spoke to the Licensee and stated the relative would have to leave the facility and not return until the criminal record clearance had been completed. The Licensee arrived at 11:00 am. The Administrator instructed the relative they would have to leave the facility until the clearance has been completed. LPA observed the relative left the facility at 11:15 am with the Licensee.

LPA and the staff member toured the facility at 10:10 am until 10:50 am. LPA Spaeth observed the following:

Kitchen - LPA Spaeth observed a two day supply of perishable food and a seven-day supply of non-perishable canned goods. At 10:20 am, LPA observed the medication cabinet was not locked. LPA instructed the caregiver to lock the cabinet. At 10:25 am, LPA observed the knives were stored in the pantry and the pantry was not locked. The staff member locked the knives in the medication cabinet.

Common Areas –The living room and dining room are combined and contained comfortable seating along with dining room table and chairs. The family room contained comfortable seating and a television.
Cont'd on 809-C
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNABELLE'S COTTAGE
FACILITY NUMBER: 197604938
VISIT DATE: 06/19/2024
NARRATIVE
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Bathroom – The bathroom contained grab bars, slip resistant mats, paper towels and a covered trash can. The water temperature was tested at 10:45 am and was 120 degrees F.

Backyard –The backyard contained comfortable seating. The gate leading from the backyard to the front yard was not locked. LPA observed a rake and shovel were located in the backyard. The caregiver locked both gardening tools in the garage.


Laundry Area – The laundry room was locked and contained cleaning solutions, washer/dryer, and laundry detergent. The garage did not contain any hazardous items and the garage was locked. The staff room is located in the garage and was locked. .

Egress System - At 10:55 am, LPA checked all exit doors and observed the system was not working. The Administrator called a repairman to fix the system.

Smoke/Carbon Monoxide Detectors - The smoke/carbon monoxide detectors were tested at 11:10 am and were properly working.


Residents’ Records -LPA reviewed residents' records at 11:20 am until 11:00 am. LPA observed R1’s file did not contain an updated Physician’s Report.

Staff Records - LPA reviewed five staff records at 1:15 pm until 2:15 pm. LPA Spaeth observed S1 had not completed the required CPR/First aid training. LPA Spaeth spoke to S1 at 1:45 pm who confirmed they had not completed the training.

LPA attempted to contact the Administrator via phone call at 2:00 pm to discuss the deficiencies. However, LPA was unable to reach the Administrator.

Based upon LPA's observations, the following deficiencies were cited (see 809-D page).

Exit interview conducted, appeal rights discussed and a copy of the report was given.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/19/2024 08:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ANNABELLE'S COTTAGE
FACILITY NUMBER: 197604938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 LPA's review of staff records, the licensee did not comply with the section cited above. Based upon LPA's review of Staff (S1) records, the staff member has not completed the CPR/first aide training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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The Administrator will forward a copy of S1's completed CPR/first aide training via email to LPA Spaeth
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Spaeth's entrance to the facility, LPA observed a relative of the caregiver who has not obtained a criminal record clearance. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA Spaeth obseved the relative left the facility at 11:15 am.
POC Due Date: 06/19/2024
Plan of Correction
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LPA Spaeth observed the relative left the facilty at 11:15 am during LPA's visit to the 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.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/19/2024 08:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ANNABELLE'S COTTAGE
FACILITY NUMBER: 197604938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the knives and the gardening tools were not safely locked. The licensee did not comply with the section cited above in two out of two incidents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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During LPA's visit, LPA observed the caregiver securely locked the knives in a locked cabinet and locked the gardening tools in the garage.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. The medication cabinet was not locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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During LPA's visit, the medication cabinet was locked.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 06/19/2024 08:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ANNABELLE'S COTTAGE
FACILITY NUMBER: 197604938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. The egress system was not properly working which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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The Licensee will send a video to LPA Spaeth via cell phone showing the egress system is now properly working on all exits.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5