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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:42:56 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,
, 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:
02/10/2022
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Marshall SanjuanTIME COMPLETED:
03:27 PM
ALLEGATION(S):
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Heater is not working in client bedroom
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint investigation for the allegation listed above. LPA arrived at the facility at 02:36 PM and met with facility staff Marshall Sanjuan. Licensee Floro Cortes was not available during today's visit. Entrance interview conducted.

During an initial complaint visit on 01/27/2022, 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, and LPA received copies of documents pertinent to the investigation.

During today's visit, LPA Dulek, along with facility staff, tested heaters in 3 different client rooms, in 3 different buildings, interviewed staff throughout the visit, and conducted a resident interview at 2:45 PM.

Heaters were tested in 3 client rooms and 0 (zero) out of the 3 heaters were functional at the time of the visit.
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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 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: 02/10/2022
NARRATIVE
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Facility staff was unable to repair the heaters during the visit. 3 clients interviewed indicated the heaters do not work. Based on interview and observation, the allegation "Heater is not working in client bedroom" is 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 with facility staff and emailed to the Administrator.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2022
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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The licensee agreed to test all remaining heaters and repair all non-functional facility heaters and send proof to CCLD by POC due date.
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Based on observation and interview, the licensee did not comply with the above cited section, as clients stated their heaters do not work and 3 of 3 heaters tested were not functional, which poses a potential health and safety risk to clients 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:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3