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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 12/19/2024
Date Signed: 12/19/2024 01:30:28 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
11/01/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20231101170034
FACILITY NAME:COTTONWOOD, THEFACILITY NUMBER:
561702356
ADMINISTRATOR:FLORO P CORTES JRFACILITY TYPE:
735
ADDRESS:1417 LIRIO AVENUETELEPHONE:
(805) 647-6046
CITY:SATICOYSTATE: CAZIP CODE:
93004
CAPACITY:24CENSUS: 21DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Marcial San JuanTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility personnel records are not maintained for staff
Resident records are not maintained by staff
Staff are mismanaging resident's medication
Staff did not ensure that resident attended scheduled doctor's appointments
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit with the purpose of delivering findings for the allegations listed above. Upon arrival, LPA met with facility staff Marcial San Juan and explained the reason for the visit. Entrance interview conducted.

During a visit conducted on 12/04/2024, LPA Dulek obtained copies of pertinent documents, toured the facility with facility staff at 12:31PM, interviewed Administrator telephonically at 01:02PM, staff at 01:35PM, interviewed clients from 02:45PM to 03:05PM, and reviewed medications at 03:16PM. During an initial complaint visit conducted on 11/06/2023, beginning at approximately 04:00PM, LPA Brian Balisi conducted physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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 5
Control Number 29-AS-20231101170034
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: 12/19/2024
NARRATIVE
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Continued from LIC 9099 (p.1)

During the initial complaint visit, LPA Balisi obtained copies of documents found in the staff files and during the subsequent visit, LPA Dulek reviewed staff files. Of 4 (four) staff files reviewed, all were missing documentation to verify staff training, 1 (one) was missing a health screening and tuberculosis test results, 1 (one) was missing a personnel report/resume, and 2 (two) were missing a criminal record statement. Staff interviewed stated that training had been provided, but documentation was not signed off and filed appropriately to date. Documents obtained during the initial complaint visit included training hours from 2022 for 1 (one) staff. There were no copies of the aforementioned documents identified as missing during the 12/04/2024 file review collected during the initial visit. Interview with Administrator revealed that the Administrator maintains all employee files, and on occasion receives assistance with auditing employee files.

During the subsequent complaint visit, LPA Dulek reviewed 4 (four) client files. Of the 4 (four) files reviewed, LPA observed the following: Medical assessments for all 4 (four) clients were dated between 2020 and 2022, needs and service plans for all 4 (four) clients were dated between 2019-2021, and only 1 (one) client file contained a mental health intake assessment.

According to staff interviewed, Client #1 (C1), who was mentioned in the complaint, has not had a medical exam in some time. Staff stated that C1 typically leaves the facility early in the morning and does not return until 5:00PM or later most days. Even when staff have reminded C1 that they have a medical appointment, C1 leaves the facility and misses the appointment. As a result of C1 not attending scheduled medical appointments, the facility was unable to obtain C1’s medications from the pharmacy at the time of the complaint. Facility staff contacted C1’s medical provider, who indicated they were unable to refill C1’s medications until C1 was seen by their medical provider. C1’s medical provider informed facility staff that they are able to take C1 to the urgent care associated with the medical practice after hours, which would fulfill the requirement of seeing the medical provider and therefore, C1’s medications could be refilled. However, at the time of the subsequent visit, facility staff had not taken C1 to the urgent care or to a regularly scheduled medical appointment. C1’s file did not contain any documentation related to notifying C1’s responsible person of the missed medical appointments nor any documentation of scheduled appointments with C1’s medical provider. Facility employees interviewed acknowledged C1 was missing medications for some time due to C1 not attending medical appointments.

Continued on LIC 9099-C (p.3)

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20231101170034
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: 12/19/2024
NARRATIVE
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Continued from LIC 9099-C (p.2)

Based on interview and record review, the preponderance of evidence standard has been met, therefore 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. A copy of today’s report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20231101170034
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: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
80070(a)
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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
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Facility staff will discuss maintenance of client files with Administrator/Licensee. Files for all clients will be updated and proof of correction will be sent to CCL by POC due date.
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Based on interview and record review, the licensee did not comply with the above cited section, as 4 client files reviewed were not complete, each missing different documents, which poses a potential health and safety risk to persons in care.
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Type B
01/06/2025
Section Cited
CCR
80066(a)
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80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
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Facility staff will discuss maintenance of staff files with Administrator/Licensee. Files for all staff will be updated and proof of correction will be sent to CCL by POC due date.
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Based on record review, the licensee did not comply with the above cited section, as 4 of 4 staff files reviewed did not contain all information/documents required, which poses a potential health, safety 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: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20231101170034
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: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2025
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
This requirement is not met as evidenced by:
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Facility staff stated C1 has a medical appointment scheduled for 01/07/2024. Facility staff stated that C1 will be taken to urgent care that same evening should C1 not attend the scheduled appointment. Proof of medical assessment will be sent to CCL by POC due date.
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Based on interview and record review, the licensee did not comply with the above cited section, as facility staff did not ensure C1 attended medical appointments, resulting in C1's medical provider not able to refill medications, which posed a potential health 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: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5