Annabelle's Cottage II

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Evelin Rios made an unannounced case management visit to this facility. LPA met with the house manager and explained the reason for the visit is to inform the Licensee that the licensing fees are past due. LPA was also at the facility to follow up on the status of a fire clearance request and hospice waiver request. During today’s visit, LPA was provided a receipt confirming that payment for the past due licensing fees, totaling $1,484.00, was paid today. On 04/14/2026, the facility was cited because two (2) of six (6) residents identified as non-ambulatory were residing in bedrooms approved only for ambulatory residents. During the same visit, the licensee had failed to submit a waiver request to increase their hospice capacity from three (3) to four (4), despite retaining a fourth terminally ill resident. Today, at 3:35 p.m., LPA spoke to Anne Gregorio, the Licensee on the telephone. LPA informed the licensee that a waiver/exception request was returned to the licensee requesting further clarification regarding hospice. According to the Licensee one (1) of the four (4) residents receiving hospice services has a scheduled reassessment as they may no longer be recertified to receive hospice services. They will still submit a waiver to the department to increase the Hospice Waiver. The licensee also stated they are in contact with the Fire Inspector and a final fire inspection visit is pending. Since the 04/14/2026 visit two (2) residents have left the facility and two (2) new residents were admitted. Residents are currently placed in appropriate ambulatory and non-ambulatory bedrooms. No immediate health or safety issues observed during today's visit. No deficiencies cited. Exit interview conducted and a copy of this report provided to the House Manager.the state’s words, verbatim · CDSS document, Jul 17, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by the Caregiver/Designee, Maria Ana Rodriguez. LPA signed in and checked their temperature on a thermometer affixed to the wall. In the facility LPA observed two (2) caregivers and six (6) residents. The Caregiver/Designee informed the Licensee, Anne Gregorio that LPA was at the facility. The administrator, Daisy Hailey and the licensee will not be able to meet with LPA today. LPA explained the reason for the visit. At 9:05 AM, LPA initiated a physical plant tour of the facility inside and out and the following was observed. LPA observed appropriate postings at the entry of the facility which included a facility sketch and LIC610E. The facility has an open concept space with the living room, dining area and kitchen. The areas were clean, clear of clutter and were properly furnished. The 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 observed two carbon monoxide detector one by the entry and another in the hallway by bedroom #3 and #4. They were tested and observed functioning properly. 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. LPA observed one (1) fire extinguisher fully charged with a last serviced date of 05/08/2025. 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 a 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) (Continued from LIC809) LPA observed the doorways to room #3 with gaps on the flooring. The rugs used to cover the doorway to room #4 were observed lifted at the corners. 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 117°F and 118 °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. The 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 backyard, LPA observed a covered patio and outdoor furniture for resident use. Passageways were clear of obstructions and there were no bodies of water observed. At 10:25 AM, LPA observed a caregiver test smoke detectors in the hallway, in bedroom #1, #3, #4 and #5. Detectors were observed to be functioning properly. At 10:32 AM LPA reviewed the register of facility residents (LIC9020) and the Personnel Report (LIC500). According to the Caregiver/Designee the LIC500 needed to be updated. LPA reviewed the Emergency Disaster Plan (LIC610E), Liability Insurance Certification and outdated emergency disaster drills. LPA was not provided documentation that an emergency disaster drill had been conducted in the last quarter. At 10:49 AM, LPA conducted a file review of six (6) of six (6) resident records to ensure compliance with licensing forms. Review of Resident#1 (R1's) Physician's Report (LIC602) notes their ambulatory status as nonambulatory. Review of the facility's approved Fire Inspection (STD850) and facility sketch shows Room #1 where R1 is residing is cleared for an ambulatory resident only. Review of Resident#2 (R2's) Pre-placement notes their ambulatory status as nonambulatory and Room #2 where R2 is residing is cleared for an ambulatory resident only. Facility had submitted a request to update ambulatory status in 2019 but LPA did not see evidence or was provided evidence from the licensee that it was processed. R2 has an admission date of 02/15/2026 without a medical assessment on record. Facility has a Hospice waiver for three (3) but currently based on resident records and staff interview four (4) residents are receiving Hospice services for a terminal illness. LPA reviewed medication and medication records for proper documentation. LPA conducted a file review of two (2) staff records to ensure compliance with licensing forms. Two (2) out two (2) staff have expired First Aid/CPR certification. Exit interview conducted. Deficiencies cited (refer to LIC809-D). Appeal rights explained and provided. Copy of report provided to the designee.the state’s words, verbatim · CDSS document, Apr 14, 2026

The state marks this report as 12 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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) (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.the state’s words, verbatim · CDSS document, Apr 2, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Mar 14, 2024