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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 03/22/2024
Date Signed: 03/22/2024 04:43:08 PM

Document Has Been Signed on 03/22/2024 04:43 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
WOODLAND HILLS N.ASC, 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: 23DATE:
03/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Floro CortesTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Administrator Floro Cortes and explained the reason for the visit. At 3:40 p.m. administrator Floro left the facility and authorized staff Romeo Sapida to review and sign the report.

The reason for today's inspection is to follow up on a self-reported death report received on 03/21/2024. The report pertains to the death of Client #1 (C1). Per the information received, the circumstances surrounding the death of C1 on 03/14/24 may be questionable and needs to be investigated. Emergency services and law enforcement were called to the facility on the day of C1's death.

During today's visit, the LPA conducted interviews with the administrator, one (1) staff, one (1) client, conducted a brief tour of building 1 and obtained copies of pertinent documents.

Further investigation is required prior to issuing findings. An investigator or the LPA will return at a later date.

Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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