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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 08/17/2021
Date Signed: 08/18/2021 08:44:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2021 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20210817111103
FACILITY NAME:COTTONWOOD, THEFACILITY NUMBER:
561702356
ADMINISTRATOR:FLORO CORTESFACILITY TYPE:
735
ADDRESS:1417 LIRIO AVENUETELEPHONE:
(805) 647-6046
CITY:SATICOYSTATE: CAZIP CODE:
93004
CAPACITY:24CENSUS: 23DATE:
08/17/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Floro CortesTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Faciltiy does not have hot water
INVESTIGATION FINDINGS:
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During todays unannouced complaint visit, Licensing Program Analyst (LPA) Angel Ascencio toured the facility at 3:07 PM and conducted staff and resident interviews starting at 3:00 PM. Entrance interview conducted with staff #1 (S1). Admin Floro Cortes arrived at the facility at 3:28 PM.

Regarding the allegation: Facility does not have hot water. Between 3:00 PM and 3:46 PM, LPA Ascencio conducted staff and resident interviews. Interviews revealed that the hot water has been off for a few weeks in order to repair the shower crack on the floor. Interview with Admin Floro Cortes at 3:29 PM, revealed that the water has been off for a weeks to prevent resident from using the shower while it is being reparied. Admin stated they are looking for a contractor to fix the shower.

Continued on LIC - 9099 - C


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20210817111103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
VISIT DATE: 08/17/2021
NARRATIVE
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Based on observation and interviews conducted during the visit, the department has sufficient evidence to determine that the allegation; Facility doesn't not have hot water, are not being met. Therefore, the above allegation is SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of
Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in
civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210817111103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited
CCR
80087(a)
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80087 Building Repair (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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Administrator will provide copy of invoice repair of both water heaters. Admin will also provide invoice for repair or replacement of shower. Documentation to be provided via email to LPA.
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Based on observation and resident and staff interviews conduted, the licensee did not comply with the section cited above as the facility is not in good repair at all times
which poses a potential safety risk to residents in care.
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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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3