197607362-4-2-2025-31-AS-ERIS-DFCTS7-20250402145841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607362
Report Date: 04/02/2025
Date Signed: 04/02/2025 02:59:06 PM

Document Has Been Signed on 04/02/2025 02:59 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANNABELLE'S COTTAGE II		FACILITY NUMBER:	197607362
ADMINISTRATOR/ DIRECTOR:	DAISY HAILEY		FACILITY TYPE:	740
ADDRESS:	6218 W. AVENUE J-12		TELEPHONE:	(661) 579-9522
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 2	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Anne Gregorio / Licensee and Maira Rodriguez / Staff		TIME VISIT/ INSPECTION COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:00 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by a staff #1(S1) and granted access. LPA signed in and checked temperature. LPA informed staff #2(S2) the reason for the visit and to inform the administrator LPA was at the facility. S2 called the owner Anne Gregorio and informed her LPA was at the facility. S2 informed LPA the owner would meet with LPA shortly. There are two (2) residents present. LPA observed resident #1 (R1) in the living room with a visitor and resident #2(R2) was in their private bedroom. At 10:16 a.m., LPA toured the physical plant of the facility inside and out and the following was observed. Common Areas: LPA observed appropriate postings at the entry of the facility. The facility maintains a comfortable temperature of 76°F. The living room and dining area were clean, clear of clutter and were properly furnished. 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 tested two (2) of two (2) carbon monoxide detectors and they were observed functioning properly at 10:23 a.m. Kitchen: 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. On a wall leading to the kitchen LPA observed one (1) fire extinguisher fully charged with a last serviced date of 05/02/2024. Bedrooms: 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 one 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: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNABELLE'S COTTAGE II	FACILITY NUMBER: 197607362
	VISIT DATE: 04/02/2025

NARRATIVE

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(Continued from LIC809) Bathrooms: 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 119.1°F and 120 °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. Laundry/Garage: 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 garage LPA observed a freezer with food and extra facility storage. At 10:54 a.m., LPA observed S2 test the hardwired, interconnected smoke detector located throughout the facility. Detectors were observed to be functioning properly. Outside Areas: LPA toured the outside area of the facility. LPA observed a covered patio and outdoor furniture for resident use. Passageways were clear and there were no bodies of water observed.

LPA met with the Licensee. LPA observed a register of facility residents (LIC9020) and observed resident #3's (R3's) name. According to staff and the license R3 passed away on February 10, 2025. Licensee informed LPA the report would have been faxed to the regional office. LPA advised report was not found on file. At 12:15 p.m., LPA met with staff #3(S3) who will be signing todays report.

Resident Files: At 12:26 p.m., LPA conducted a file review of one (1) of two (2) resident records to ensure compliance with licensing forms. Medications: LPA and S3 reviewed medication and medication records for proper documentation. Staff Files: LPA conducted a file review of four (4) staff records to ensure compliance with licensing forms. S1 was designated as a volunteer. LPA observed S1 providing assistance to R1 with other staff present. Two (2) out of four (4) records reviewed are missing health screening documentation to verify staff are physically and mentally capable of performing assigned tasks. S1 was missing a signed statement affirming that he/she is in good health and a chest x-ray or an intradermal test on file. LPA observed an LIC500 and Resident Roster. Certificate of Liability Insurance will be emailed to LPA. At 2:28 p.m., LPA reviewed R2's record to ensure compliance with licensing forms.

Exit interview conducted. Deficiencies cited (refer to LIC809-D). Appeal rights explained and provided. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/02/2025 02:59 PM - It Cannot Be Edited

Created By: Evelin Rios On 04/02/2025 at 02:16 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: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

Reporting Requirements

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in not providing a writing notification to the regional office of resident #3's (R3's) passing which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2025
	Plan of Correction
1 2 3 4	Administrator will email a death report to LPA by POC due date and a copy of resident's death certificate when possible.

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 staff files reviewed did not have proper or completed health screening documentation which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2025
	Plan of Correction
1 2 3 4	Administrator will provide copies of staff completed health screening (LIC503) regarding physically and mentally capable of performing assigned tasks, and provide a copy of volunteer's TB test results to LPA 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.

	Eva Miller
NAME OF LICENSING PROGRAM MANAGER:

	Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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