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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:28:23 PM

Document Has Been Signed on 04/08/2024 02:28 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/
DIRECTOR:
FLORO P CORTES JRFACILITY TYPE:
735
ADDRESS:1417 LIRIO AVENUETELEPHONE:
(805) 647-6046
CITY:SATICOYSTATE: CAZIP CODE:
93004
CAPACITY: 24CENSUS: 22DATE:
04/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Floro CortesTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit to the above facility. The LPA initially met with House Manager Marcial San Juan. House Manager contacted Administrator, who arrived at the facility at 01:40PM. Entrance interview conducted.

The reason for today's inspection is to follow up on a self-reported incident report that was sent to the Woodland Hills Regional Office late on Friday 04/05/2024. Incident report indicates that Individual #1 (I1), who is a close confidante of Client #1 (C1), spoke with Administrator on 04/04/2024. I1 indicated that they had a conversation with C1, in which C1 reported that they had been sexually assaulted by Client #2 (C2) on 03/21/2024 in their shared room at the facility. Also included with the incident report was an additional incident report involving a behavior incident and hospitalization of C1 that occurred on 03/21/2024.

During today's visit, the LPA conducted an interview with Facility Administrator at 01:42PM, toured the facility with Administrator at 01:55PM, and LPA received copies of pertinent documents. No immediate health and safety concerns were noted during today's facility tour.

Further investigation is required prior to issuing findings. Administrator was advised that this incident was referred to CCLD's Investigations Branch (IB). Either an IB investigator or the LPA will return at a later date to continue the inspection.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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