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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607362
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:53:20 PM


Document Has Been Signed on 03/14/2024 01:53 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:DAISY HAILEYFACILITY TYPE:
740
ADDRESS:6218 W. AVENUE J-12TELEPHONE:
(661) 579-9522
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Eufemioike RodriguezTIME COMPLETED:
02:20 PM
NARRATIVE
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At 9:50 a.m. Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by a caregiver and granted access. Caregiver requested LPA check temperature on temperature reader affixed to the entry wall and asked LPA to sign in. LPA called the Administrator Daisy Hailey and notified Administrator reason for the visit. Administrator would not be present and assigned Caregiver Eufemioike Rodriguez to sign the report. Caregiver is the only staff member currently present at the facility. There are four (4) residents present.

LPA observed that there is one (1) bedridden resident, but facility is not approved or have a fire clearance for bedridden. Facility is approved for two (2) ambulatory and four (4) non-ambulatory with three (3) hospice waivers. Three (3) residents are on Hospice Care. LPA explained to Caregiver that an immediate civil penalty of $500 would be issued.

At 11:30 a.m. LPA and Caregiver toured the physical plant of the facility, and the following was observed.

Common Areas: The facility maintains a comfortable temperature at 75°F. The living room and dining area appeared clean and were properly furnished. No obstructions or tripping hazards throughout the facility. LPA observed all trash cans throughout the facility have fitted lids.

Kitchen: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed cleaning products kept locked under the kitchen sink. LPA observed knives locked in a kitchen drawer. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food properly stored. On a wall leading to the kitchen LPA observed one (1) fire extinguishers fully charged with a last serviced date of 05/08/2023. Dining area had a table and chairs to sit the capacity of the facility.



Continued on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 01:53 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.RO, 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: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
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: (2) Bedridden persons

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 by accepting one (1) bedridden resident without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Administrator agreed to complete and submit LIC200 along with the facility sketch to Fire Department for a Bedridden and non-ambulatory approval by POC date. Bedridden plan of operation and proof will be submitted to LPA via email by POC due date.
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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2024 01:53 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.RO, 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: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and records review, the licensee did not comply with the section cited above by only having one (1) caregiver to assist four (4) out of four (4) residents and not having additional staff to perform necessary work, which poses a health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Administrator will submit a new LIC500 reflecting all shift coverage for facility that is adequate for all residents in care by email to LPA on 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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2024 01:53 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.RO, 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: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705(c)(5) Dementia Resident Annual Medical Assessment: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:…(5)Each resident with dementia shall have an annual medical assessment …Medical Assessment, and a reappraisal done at least annually…
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and records review, the licensee did not comply with the section cited above by not having an annual medical assessment in three (3) out of four (4) residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Administrator will provide updated Medical Assessments for all four residents via email to LPA by POC due date.
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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2024 01:53 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.RO, 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: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(D)
87307(a)Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(2)Resident bedrooms shall be provided which meet, at a minimum, the following requirements:(D)Not more than two residents shall sleep in a bedroom.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in allowing one (1) out five (5) residents bedroom to be occupied by a resident and staff in resident's shared bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Staff immediately removed air mattress from resident's shared bedroom. POC cleared on today’s visit.
Type B
Section Cited
HSC
1569.267
The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review the licensee did not comply with the section cited above in two (2) out of three (3) staff records that revealed staff do not have ongoing training on Resident's Bills of Rights to ensure the resident's rights are fully respected and implemented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Administrator will conduct in house training of the Resident's Bill of Rights and review Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders document with all staff. Administrator will submit to LPA via email a copy of the training conducted, signed and dated by staff and administrator 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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


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: 03/14/2024
NARRATIVE
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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 private resident room to be properly furnished with one bed, appropriate nightstand, chair, bedding and with sufficient lighting and storage. LPA observed an air mattress and twin bed in the shared bedroom. LPA asked Caregiver who sleeps in the air mattress and Caregiver indicated they sleep in the shared room occupied by one resident. Caregiver was asked to remove the air mattress.
Bathrooms: The facility has three (3) bathrooms. Water temperature in bathrooms was measured, temperature was 117.5 degrees Fahrenheit. LPA observed the bathrooms to be clean and properly supplied with toilet paper and trash bins with lids.
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. At 11:50 a.m. LPA observed Caregiver test the hardwired, interconnected smoke detector located throughout the facility. Detectors were observed to be functioning properly. LPA observed the carbon monoxide detector functioning properly.

Outside Areas: LPA toured the outside area of the facility. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. There were no bodies of water observed.



Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Yearly Physician reports were missing in three (3) out of four (4) records.

Staff Files: LPA conducted a file review of staff records to ensure compliance with licensing forms. Two (2) out of three (3) staff records are missing ongoing training.

Medications: LPA and Caregiver reviewed medication and medication records for proper documentation.

Administrative: Annual fees are current. LPA collected LIC500 and Resident Roster. Certificate of Liability Insurance will be emailed to LPA.

Please see LIC809-D for civil penalties and citations. Citations issued during this visit. LPA explained civil penalty of $500 would be issued and that two (2) repeat violation civil penalties of $250 each would be issued. Appeals rights explained and provided. Exit interview conducted. Copy of report given to the Caregiver.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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