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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 01/27/2022
Date Signed: 01/27/2022 05:15:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2022 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20220119131144

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:
01/27/2022
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Floro CortesTIME COMPLETED:
03:21 PM
ALLEGATION(S):
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Facility staff are only serving clients cereal for breakfast daily
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 01:25PM and initially met with facility staff Elvia Lemus. Licensee Floro Cortes was contacted via telephone and arrived at the facility at 01:45PM. Entrance interview conducted.

During today's visit, LPA toured the facility with staff Elvia Lemus at 1:31PM, interviewed Administrator and staff at 01:45PM, conducted resident interviews from 02:05PM until 02:50PM. LPA received copies of documents pertinent to the investigation.

During the facility tour, LPA observed a variety of foods in the facility storage pantry, refrigerator, freezer, as well as in the facility kitchen. The facility menu is posted and when there is a change to the menu, staff hand writes in the alternate items served on the menu itself. Interviews revealed that there are a variety of foods
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220119131144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
VISIT DATE: 01/27/2022
NARRATIVE
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served at breakfast time, including eggs, sausage, toast with peanut butter, pancakes, and oatmeal. Drinks such as juice, milk, and coffee are offered to the clients with their breakfast. Staff indicated many clients only ask for cereal in the morning, however alternate foods are prepared and offered to the clients. LPA observed leftover scrambled eggs stored in the refrigerator that had been served for breakfast on the morning of LPA's visit. Based on observation and interview, the allegation that "Facility staff are only serving clients cereal for breakfast daily" is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted with Floro Cortes. A copy of the report was provided via email.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3