197604938-8-3-2023-31-AS-MSPH-CUCKPM-20230803080457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 08/02/2023
Date Signed: 08/03/2023 08:05:02 AM

Document Has Been Signed on 08/03/2023 08:05 AM - 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 COTTAGE		FACILITY NUMBER:	197604938
ADMINISTRATOR:	DAISY HAILEY		FACILITY TYPE:	740
ADDRESS:	3732 VITRINA LANE		TELEPHONE:	(661) 947-0052
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	5	CENSUS: 3	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Louie Gamutan		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by Caregiver. The Administrator was at an appointment; however, LPA Spaeth spoke to the Administrator via phone at 9:30 am. The facility is licensed as a Resident Care Facility for the Elderly to serve five residents of which five may be non-ambulatory and one bedridden. There are three residents living in the facility.

LPA reviewed residents' records at 9:40 am until 10:15 am.

LPA and Caregiver began the tour of the facility at 10:20 am until 11:00 am. LPA observed the following:

Kitchen – LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. LPA observed the knives were locked in a kitchen drawer and medications were locked in the kitchen cabinet. The fire extinguisher is located in the kitchen area.

Common areas – LPA Spaeth observed the living room and dining room combination contained comfortable seating and a dining room table with chairs. LPA observed the family room also contained comfortable seating and a television.

Bathrooms – LPA Spaeth observed both bathrooms contained hand soap, paper towels, slip resistant mat, and a trash can. Water temperature was tested at 10:45 am at 122.0 F.

Bedrooms – LPA Spaeth observed there are three bedrooms in the facility and two of the bedrooms are occupied by residents. The bedrooms contained bed, linens, night stand, and night lamp.

Laundry Room – LPA Spaeth observed the laundry room was locked. The washer/dryer, cleaning supplies, and laundry soap are safely locked in the laundry room.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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: 08/02/2023

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Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke detectors were tested at 10:50 am. The carbon monoxide detector is operational and located in the family room.

Delayed Egress System- LPA Spaeth observed the delayed egress system was properly working on all five exit doors.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to caregiver.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2023 08:05 AM - 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: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(f)

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Spaeth observations, the staff records were not available to LPA, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Administrator will ensure staff files are located at the facility for LPA's review. Administrator will send a copy of staff training records to LPA by 8/07/2023 via email.

Type A

Section Cited

CCR

87355(d)(3)

Criminal Record Clearance

(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Spaeth observations, the licensee did not comply with the section cited above in one out of five staff members which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	LPA Spaeth observed S1 left the facility at 2:00 pm.

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 Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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