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Inspection visit

Routine inspection

ANNABELLE'S COTTAGELicense 19760493823 citations on this visit
23 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPA’s) Spaeth, Avetisyan and Stamps conducted an unannounced visit to the facility. Upon arrival LPA’s observed the front door did not contain the COVID signage. LPAs were greeted by Ringo Torres Caregiver at 11:19 am. Upon entering the facility, LPA’s observed the sign in station which contained thermometer, hand sanitizer and a sign in sheet. LPA Spaeth reminded the caregiver the requirement to take LPAs temperature. All LPAs temperatures were then taken and recorded. Caregiver called the licensee who arrived at the facility approximately 11:55 am. The initial purpose of the visit was to determine if Resident 1 (R1) who was named in an unlicensed care complaint was living at this facility, however during the visit LPA’s observed various deficiencies and determined that a required Annual Visit would be conducted as well. Approximately 11:25 am LPAs conducted a tour of the facility and observed a living room/dining room combination. As well as a kitchen/family room combination. The facility has four rooms designated for resident use and 2 residents residing at the facility. All resident rooms contained the required furnishing and proper linens. At 12:00 pm, LPAs observed full bed rails in Room #4 and 1/2 bed rails in Room #1. During the tour LPA’s observed that the master bathroom did not have the "wash your hands" sign not posted. LPA’s observed slip resistant mat and hand bars near the toilet and shower. LPA Spaeth informed staff that a "wash your hands" sign needs to be posted in the bathroom. The facility has a separate locked laundry room which contained washer and dryer, cleaning supplies, and laundry detergent. While conducting a tour of the kitchen LPA” s observed knives and medication properly secured. The refrigerator was observed to be dirty at which time LPA Spaeth informed the caregiver that the refrigerator will need to be cleaned. LPA’s did not observe sufficient supply of fruits and vegetables as well as insufficient supply of 7-day non-perishable food. LPA Spaeth informed the licensee of the deficiency. Approximately 11:54 am LPA Avetisyan requested the assistance of caregiver to test the smoke/carbon monoxide detectors. During the test LPA Avetisyan and Stamps observed that the 2 smoke detectors and 2 carbon monoxide detectors were not operational. A discussion was held with the licensee regarding the zero-tolerance deficiency as well as concerns of the alarms on all exit doors not working. The licensee informed the LPA’s that the alarm system was disconnected by staff approximately 2 months ago due to issues with the system. At 12:15 pm, LPA Avetisyan conducted review of resident facility and hospice files. LPA requested to see the facility file for resident 2 various times which the licensee and caregiver could not locate. While reviewing the hospice files, LPA Avetisyan did not observe a current hospice care plan for both residents. Approximately 12:30 pm LPA’s conducted a tour of the backyard and observed an electric table saw, screwdriver, dis-assembled bed, dirty mattress, 2 Hoyer lifts and various other items. Administrator was reminded that these items are a safety issue for the 2 residents in care. Approximately 1:00 pm LPA’s requested to review the medication records for resident. Licensee and staff searched but could not locate the file. Approximately 1:30 pm LPA’s conducted review of staff files and observed that staff do not have current first aid/CPR, have not received training since 2017. At 1:45 pm LPA asked the licensee how many staff she has working at the facility. Licensee informed LPA that she has 2. Staff Ringo Torres works at the facility Monday through Friday and another staff works at the facility on the weekends. LPA asked the licensee where the caregiver sleeps. Licensee informed LPA that the staff sleep in the converted staff room in the garage. At 2:23 pm LPA Avetisyan and Stamps requested for the administrator to show them the staf room. LPA’s along with caregiver walked to the laundry room, entered another door in the laundry room to the garage. To the left of the garage LPA’s observed 2 separate rooms which licensee confirmed is being utilized by the 2-current staff. LPA’s observed baby monitor hanging from the garage refrigerator. At 2:26 pm caregiver stated that monitors are used to supervise the residents at night. At 2:30 pm LPA Avetisyan requested to review the file for the administrator which the licensee could not provide. At 2:40 pm LPA called the administrator on record who stated that she no longer works for the licensee and has not worked since the start of the pandemic. LPA’s asked the licensee to explain why she lied to them about the administrator, which the licensee could not provide an answer. A discussion was held with the licensee regarding the seriousness of the deficiencies observed and cited, the immediate health and safety concerns for the residents in care and the current inactive status of the corporation. Licensee was informed that she will need to ensure that all deficiencies are corrected immediately which the licensee indicated she would Exit interview conducted, copy or report, citations, civil penalties and appeal rights emailed to ANNILISCIOUS@GMAIL.COM .

Citations

23 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.311Type A

    1569.311 Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility...This requirement is not met as evidenced by: Based on observation and interviews, licensee failed to ensure the facility had one or more carbon monoxide detectors at the facility which poses an immediate health and safety risk to residents in care.

  • 1569.605Type B

    Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...This requirement was not met as evidenced by: Based on interview, the licensee did not comply with the section cited above as the failing to obtain/maintain liability insurance which poses a potential health, safety, personal rights risk to persons in care.

  • 1569.625(b)Type B

    1569.625(b) Staff training; legislative findings; contents. (1) The department ...staff members ...who assist residents with personal activities of daily living to receive ... training. This training shall consist of 40 hours of training. ...(2) training requirements shall also include an additional 20 hours annually…. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care.

  • 1569.69(a)Type B

    1569.69(a) Each residential care facility...shall ensure ... employee ... who assists residents with the self-administration of medications meets... training requirements: This requirement is not met as evidenced by: Upon review of the staff records, LPA observed staff has not completed the required medication trainnig.

  • 1569.696(a)Type B

    1569.696(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care...the training requirements specified in .... The training shall include all of the following: This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care.

  • 80020(a)Type A

    Fire Clearance Violations, including, but not limited to, over capacity, ambulatory status, inoperable smoke alarms, and inoperable fire alarm systems. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, This is not met as evidenced by observation and inteview the licensee did not comply with the regulation above by not ensuring the smoke detectors are operational which poses an immediate health,safety personal rights risk to persons in care.

  • 87205(b)Type B

    87205 (b) Accountability of Licensee Governing Body-(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by: the licensee did not comply with the section cited above by not ensuring that the corporation remains active which poses a potential health, safety and personal rights risk to persons incare.

  • 87207Type A

    False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by providingfalse/misleading statement regarding the designated facility administrator.

  • 87305(a)Type A

    87305(a) Alterations to Existing Building or New Facilities Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above by building unpermitted staff rooms in the garage which poses an immediate health, safety and personal rights risk to persons in care and staff.

  • 87405(a)Type B

    87405(a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a certified administrator working which poses a potential health, safety, personal rights risk to persons in care.

  • 87411(c)(1)Type B

    87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not ensuring 5 out of 8 staff received first aid training which poses a potential health, safety or personal rights risk to persons in care.

  • 87411(d)(5)Type B

    87411(d)(5) (d) All personnel shall be given training... This training ...shall provide knowledge of and skill in the following,.. for the job assigned and ... job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not providing staff training on infection prevention, symptoms, transmission and PPE use by any individual trained in infection control which poses an immediate health, safety or personal rights risk to persons in care.

  • 87411(f)Type B

    87411 (f) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by. Based on interview, the licensee did not comply with the section cited above by not having qualified staff on the premises at nights resulting in absence of supervision for the 2 residents in care which poses an immediate health, safety personal rights risk to persons in care.

  • 87465(b)(c)(d)Type B

    Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by notobtaining PRN authorization letters for 2 residents which poses a potential health,safety or personal rights risk to persons in care.

  • 87465(h)(6)(6)Type B

    87465 (h)(6) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications ... is maintained for at least one year and includes… This requirement is not met as evidenced by:Based on interview and record review, the licensee did not comply with the section cited above by not completing/retaining centrally stored medication & destruction record for 2 out of 2 residents which poses a potential health, safety and personal rights risk to persons in care

  • 87468.1(a)(2)Type B

    Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above by not conducting routine symptom screening for resident,staff & visitors which poses an immediate health, safety, personal rights risk to persons in care.

  • 87468(a)(1)Type B

    Residents in all residential care facilities shall have all of thefollowing personal rights: (1)To be accorded dignity in their personal relationships with staff. This requirement was not met as evidenced by: Based on observation, interview, the licensee did not comply with the section by R1 by placing a baby monitor in resident room to monitor residents at night which poses an immediate health, safety and personal rights risk to persons in care.

  • 87608(3)Type B

    87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement was not met as evidenced by: LPA reviewed resident file and did not find a written order for the resident's half bed rails.

  • 87608(a)(5)(B)Type B

    87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently on hospice care and..hospice care plan that specifies the need for full bed rails.This requirement was not met as evidenced by: Licensee did not comply with the section cited above by utilizing full bedrails for R1 who is on hospice however licensee does not have hospice care plan which indicates the need which poses an immediate health, safety personal rights risk to R1.

  • 87632(a)Type B

    In order accept or retain terminally ill residents &... receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement was not met as evidenced by: Based on record review,the licensee did not comply with the section cited above by retaining 2 residents on hospice prior to obtaining an approved hospice waiver which poses an potential health, safety & personal rights risk to persons in care.

  • 87633(b)Type B

    87633(b) A current and complete hospice care plan shall be maintained ... for each hospice resident and include the following: This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not obtaining hospice plans for R1 and R2.

  • 87705(j)Type A

    87705 Care of Persons with Dimentia (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 was not met as evidenced by: Based upon LPA's observations, the alarm on all exit doors were not working. This poses an immediate health, safety and personal rights risk to persons in care.

  • 87555(b)(26)Type A

    87555(b) General Food Service Requirements (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based upon LPA's observation the facility did not have an adequate supply of fresh fruits and vegetables and canned goods.

FAQ · About this visit

Common questions about this visit

What happened during the September 30, 2021 inspection of ANNABELLE'S COTTAGE?

This was a inspection inspection of ANNABELLE'S COTTAGE on September 30, 2021. 23 citations were issued: 6 Type A (serious) and 17 Type B.

Were any citations issued to ANNABELLE'S COTTAGE on September 30, 2021?

Yes, 23 citations were issued (6 Type A, 17 Type B). The first citation was for: "1569.311 Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one ..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.