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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:14:16 PM

Document Has Been Signed on 01/29/2024 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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: 24DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Floro Cortes, Licensee/AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:11AM. LPAs initially met with facility staff Marcial San Juan and explained the reason for today’s visit. Licensee/Administrator Floro Cortes was contacted via telephone and arrived at the facility at 09:40AM. Entrance interview conducted.

Beginning at 09:55AM, the LPAs, along with the Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers were observed throughout the facility to be fully charged and last serviced 10/18/2023. 5-year fire sprinkler inspection was completed in September 2022; no concerns were identified at that time. Combination smoke detector/carbon monoxide detectors throughout the facility were tested and were operational at the time of the visit.

KITCHEN: LPAs observed the kitchen/dining area. Kitchen appliances appear to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply and water. All knives and cleaning supplies were observed to be locked and stored in compliance with regulation.

BEDROOMS: There are 12 (twelve) total bedrooms, all of which are shared rooms and all were observed during the facility tour. Client bedrooms appeared to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Client bedroom in building 1 contains a sliding glass door, but no screen and flies were observed in client's bedroom. One client room in building 5 had flooring which was sagging and contained holes. Screens in client rooms throughout the facility were observed to be dirty.

Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2024 03:14 PM - It Cannot Be Edited


Created By: Kelly Dulek On 01/29/2024 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the common bathroom in building 1 has a floor which is sagging and appears to be experiencing wet rot, which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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During today's visit, Administrator/Licensee contacted the handyman to schedule a time to visit the facility and reinforce the floor. The floor was already planned for a larger construction project, but had no anticipated timeline for completion as of facility visit. Licensee agreed to ensure the floor is reinforced as soon as possible and provide proof to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2024 03:14 PM - It Cannot Be Edited


Created By: Kelly Dulek On 01/29/2024 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Building and Grounds
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above as in building 1, a resident room has a sliding glass door with no screen and flies were observed in the resident's room as well as all other screens throughout the facility appeared dirty, which poses a potential health and safety risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Licensee agreed to clean all screens throughout the facility and install a screen on the patio door in the client's room in building 1 and provide proof to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/29/2024
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RESTROOMS: Client restrooms were observed to contain sufficient amounts of soap and paper products in each restroom. Water temperature was tested in a sampling of client restrooms throughout the facility, which measured within the required range. Common restroom contained in building 1 had missing tiles with exposed wood, the flooring was observed to be sagging and appeared to be experiencing wet rot.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, dining room furniture was observed to be in adequate condition. The temperature was maintained at a comfortable level throughout today's visit. Cleaning supplies and disinfectants are stored locked per regulation. A working telephone is present.

OUTDOOR SPACE: The outdoor area has shaded outdoor seating areas equipped with furniture for client use. There were no bodies of water noted.

RECORD REVIEW: LPAs reviewed staff and client records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, client physician's report, needs and service appraisals, and admission agreements. 5 (five) of 5 (five) staff files reviewed contained all documents. All 5 (five) of 5 (five) client files reviewed were in compliance.

MEDICATION REVIEW: Medications for 3 (three) clients were reviewed. All 3 (three) of 3 (three) clients' medications were observed to be properly documented and in compliance at the time of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPAs reviewed the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. LPAs also reviewed the facility's emergency disaster plan, which was complete, but documented on an outdated form and not updated annually. LPAs advised Licensee to utilize the newer updated form. Disaster drills are conducted monthly, with the last drill documented on 01/25/2024.

INTERVIEWS: Throughout today’s visit, LPAs interviewed 3 (three) staff and 3 (three) clients.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Licensee/Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
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