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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 03/04/2025
Date Signed: 03/05/2025 08:21:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/25/2025 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20250225162418
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: 20DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Floro Cortes, Jr.TIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not ensure hole in wall was fixed
Staff did not clean bathroom
Staff do not ensure the facility is clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA met with administrator Floro Cortes, Jr. and explained the reason for the visit.

At 9:58 a.m. LPA interviewed the administrator. He confirmed that client 1 (C1) had a roommate who would defecate in the bathtub and had severe incontinence issues. That roommate had reached an age where they needed to be in an elderly facility and receive a higher level of care. The roommate was transferred to another facility in August of 2024. C1 has also experienced issues with incontinence and frequently requires a new mattress. The administrator estimated he replaces C1's mattress every two to three months. They put protective covers on the mattress and change the covers daily.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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-20250225162418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
VISIT DATE: 03/04/2025
NARRATIVE
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(continued from LIC9099)

At 10:32 a.m. LPA conducted a brief tour of randomly selected client rooms. LPA observed in building number two the rooms were not clean, there were holes in the walls in both rooms, one of the bathrooms had two holes covered by plywood behind the toilet. The floor in that room around the covered holes was dirty and one of the holes was not completely covered by the plywood. The hole did not lead to the outside but it did expose the wall cavity. The rug in that room was also dirty. There were holes on the entry door to the other room and there was a large hole by one of the beds. These holes were caused by the client who stays in that room. LPA also observed cigarette butts on the floor in that room.

This facility is undergoing construction remodeling of all buildings. The remodel/rehab includes electric, plumbing, bathroom fixtures, tile, flooring, kitchen, and roof. These improvements are in phases to ensure as little displacement of clients as possible. There are empty rooms available if clients need to temporarily move from their room.

Based on observations, the above noted 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 report and appeal rights were reviewed with administrator and a copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250225162418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2025
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 was not met as evidenced by:
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Licensee will have the holes in the bathroom and rooms in building two repaired and provide a photo to CCL by 3/11/2025. LIcensee wil train staff on reporting concerns and ensuring rooms are clean and provide evidence of training to CCL by 3/11/2025.
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Based on observations, the licensee did not comply with the above cited section, the bathroom and rooms in building two were in disrepair and not clean, which poses a potential health and 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: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3