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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 01/11/2022
Date Signed: 01/11/2022 04:49:33 PM

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
01/03/2022 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220103151445
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: 24DATE:
01/11/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elvia LemusTIME COMPLETED:
04:48 PM
ALLEGATION(S):
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Facility has rodents
Staff do not ensure that residents are adequately fed
Residents are not offered activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced complaint investigation visit. LPA met with staff Elvia Lemus who is authorized to review and sign reports.

During today's visit LPA toured the facility with staff, interviewed random residents and staff and obtained copies of pertinent documents. Concerns were that the facility is infested with field mice and rats and they are in resident rooms. Interviews on 1/11/22 with random residents and staff starting at 1:07 pm revealed that mice and/or rats have been observed in resident rooms. Interview with Administrator on 1/11/22 starting at 2:44 pm revealed that a resident was biten by a mouse in their room on 1/7/22. Administrator stated that the last time their exterminator was out at the facility for mice was over a month ago. Administrator stated that they had overlooked calling them regarding the current mice issue. Concerns were that staff do not ensure that the residents are adequately fed as they are not receiving fresh fruit or snacks. Interviews on 1/11/22 with random residents and staff starting at 1:07 pm revealed that residents are given fresh fruit when they ask staff Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
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 4
Control Number 29-AS-20220103151445
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: 01/11/2022
NARRATIVE
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for it. Fresh fruit is being given but not daily. LPA did not observe fruits on the facility menu for the week of 1/10/22 to 1/16/22 when reviewed at 2:21 pm. During facility tour LPA observed a sufficient supply of fresh fruit. Interview with Administrator on 1/11/22 starting at 2:44 pm revealed that they do buy fresh fruit but it is not a preferred choice of the clients. Administrator stated that they are not offering clients fruit however, if they ask for it they will give them fruit. Concerns were that clients are not being given snacks. Interviews on 1/11/22 with random residents and staff starting at 1:07 pm revealed that everyday around 6 pm clients are given snacks. LPA observed snack schedule for December 2021 at 2:23 pm which indicates snacks are being given once daily. Concerns were that residents are not being offered activities. Interviews on 1/11/22 with random residents and staff starting at 1:07 pm revealed that activities are not being offered to residents. Interview with Administrator on 1/11/22 starting at 2:44 pm revealed that they do not offer any planned activities. During facility tour LPA observed card games, board games, coloring books, crayons, and crossword puzzles. Based on the information obtained during the course of the investigation the allegations are deemed substantiated at this time.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220103151445
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: 01/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2022
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds.(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.



This requirement is not met as evidenced by:
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Administrator stated that they will contact a pest control company regarding the mice and/or rats and will provide documentation of the pest control visit for the mice and/or rats by 1/19/22.
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Based on interviews, the licensee did not comply with the section cited above as mice and/or rats were observed in the facility which poses a potential health and personal rights risk to persons in care.
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Type B
01/14/2022
Section Cited
CCR
80076(a)(1)
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80076 Food Services (a)(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide...All food shall be selected, stored, prepared and...
This requirement is not met as evidenced by:
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Administrator stated that they will review and comply with the regulation 80076(a)(1) and provide a letter indicating this to LPA by 1/14/22.
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Based on interviews and record review, the licensee did not comply with the section cited above as the facility is not providing residents with fresh fruit which poses a potential health and personal rights risk to persons 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: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220103151445
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: 01/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2022
Section Cited
CCR
80076(a)(4)
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80076 Food Services(a)( 4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.



This requirement is not met evidenced by:
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Administrator stated that they will review and comply with regulation 80076(a)(4) and will submit a letter indicating this to LPA by 1/14/22.
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Based on interviews and record review, the licensee did not comply with the section cited above as the facility is only providing snacks after dinner which poses a potential health and personal rights risk to persons in care.
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Type B
01/14/2022
Section Cited
CCR
85079(a)
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85079 Activities (a) The licensee shall ensure that planned recreational activities, which include the following, are provided for the clients:



This requirement is not met evidenced by:
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Administrator stated that they will review and comply with regulation 85079(a) and will submit a letter indicating this to LPA by 1/14/22.
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Based on interviews, the licensee did not comply with the section cited above as the facility is not providing residents with planned activities which poses a potential health and personal rights risk to persons 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: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4