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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:44:36 PM

Document Has Been Signed on 09/04/2024 03:44 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/
DIRECTOR:		FLORO P CORTES JRFACILITY TYPE:
735
ADDRESS:1417 LIRIO AVENUETELEPHONE:
(805) 647-6046
CITY:SATICOYSTATE: CAZIP CODE:
93004
CAPACITY: 24CENSUS: 21DATE:
09/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Floro CortesTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent Case Management - Incident visit. The purpose of this visit is to conclude an investigation initiated by LPA K. Dulek during a Case Management – Incident visit conducted on 04/08/2024. LPA met with licensee administrator Floro Cortes and explained the reason for the visit.

On 04/05/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received an incident report regarding Client #1 (C1) being sexually assaulted by roommate Client #2 (C2). The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laarni Santiago.

On 04/08/2024, from 1:09 p.m. to 2:35 p.m., LPA Dulek conducted an unannounced Case Management – Incident visit to the above facility. LPA Dulek initially met with House Manager Marcial San Juan. The House Manager contacted the Administrator, who arrived at the facility at 01:40pm. The LPA explained the reason for the visit was to follow up on a self-reported incident that was sent to the RO on 04/05/2024. The incident report indicated that Individual #1 (I1), who is a close confidante of Client #1 (C1), spoke with the 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 “5150” (danger to self or others) hospitalization of C1 that occurred on 03/21/2024. During the visit, the LPA conducted an interview with the Administrator at 01:42pm, toured the facility with Administrator at 01:55pm, and received copies of pertinent documents. No immediate health and safety concerns were noted during the facility tour. The LPA determined further investigation was required prior to issuing findings. The Administrator was advised that the incident was referred to CCLD's Investigations Branch (IB).

(continued on LIC809C)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
VISIT DATE: 09/04/2024
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(continued from LIC809)

On 05/01/2024, from approximately 10:39 a.m. to 3:00 p.m., Investigator Santiago conducted interviews with the Administrator, Tri-Counties Regional Center (TCRC) Service Coordinator (SC), and C1; on 06/18/2024, at approximately 2:29pm, with I1; on 06/26/2024, from approximately 9:43 a.m. to 10:30 a.m., with client #3 (C3), clients and staff; on 06/27/2024, at approximately 2:12 p.m., with C2; on 07/01/2024, from approximately 3:11 p.m. to 3:59 p.m., with C1’s family member and Ventura County Behavioral Health (VCBH) Case Manager; and on 07/02/2024, at approximately 7:40 a.m., with staff. The Ventura County Sheriff’s Department was involved pertaining to C1’s narcotic use and 5150 mental health hold, however, there was no report of sexual assault. In addition, pertinent records related to C1 and C2 were obtained and reviewed.

A review of C1’s facility file revealed that the TCRC Admission’s Agreement, signed and dated 10/20/2016, noted C1 was placed in a double room. C1’s Physician’s Report, dated 06/23/2022, noted C1 was diagnosed with Intellectual Disability and Paranoid Schizophrenia. The Medical assessment noted C1 as ambulatory; able to follow instructions; able to communicate needs; able to care for all personal needs and able to leave facility unassisted. C1 does not require constant medical supervision. C1 was dependent on staff to administer and store medications which included mood stabilizer, Bipolar, and sleep aid medications. The Appraisal/Needs and Services Plan, dated 10/26/2022, noted C1 is diagnosed with Borderline Intellectual Disability, Paranoid Schizophrenia, Psychiatric Disorder (Mood Disorder NOS and other Disorder of Psychological Development), Depression, History of Paranoia and Auditory Hallucinations and Delusions, Chronic Smoking, and history of Poly-substance dependency (marijuana, methamphetamine, and alcohol). C1 has a history of property destruction, threatening to hurt others and suicidal threats. C1 was noted to be non-compliant with medications and abused substances daily which led to poor choices and safety problems. C1 had been arrested several times with seven (7) closed cases (time served), with multiple psych hospitalizations and identified to be a danger to others and gravely disabled.

(continued on LIC809C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
VISIT DATE: 09/04/2024
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(continued from LIC809C)

A review of C2’s facility file revealed the Cottonwood facility Admission’s Agreement, dated and signed 02/03/2021. C2’s Physician’s Report, dated 07/31/2018, noted C2’s diagnosis as Schizophrenia, Paranoid type, alcohol, and cannabis dependence. C2’s Appraisal/Needs and Services Plan, dated 12/06/2017, noted C2 as diagnosed with Schizophrenia, has a history of substance abuse, but is currently in an extensive history of hospital admissions to Ventura County Medical Center. C2 presents catatonia when experiencing symptoms of C2’s diagnosis.

Information obtained during the Department’s investigation revealed that C1 maintained that C1 was “raped” while in care but declined to provide relevant details surrounding the incident. C1 reported that the assault happened in C1’s bedroom, the evening of 03/20/24 and/or early morning hours of 03/21/24. Interviews with staff that worked the evening of 03/20/24 to 03/21/24, revealed they did not witness or hear any suspicious activity in C1’s bedroom. However, they recalled that C1 presented aggressive behavior by slamming doors, pacing the hallway, and even refusing medication during that time. During the investigator’s interview with C1, C1 disclosed that C1 was raped by C1’s former roommates, C2 and C3. However, interviews with facility staff, TCRC SC, and I1 denied having knowledge that C3 sexually assaulted C1 as they were not informed by C1. When asked for more information, C1 stated, “I don’t want to talk about the incident anymore”. C1’s Individual Program Plan (IPP) and medical assessment revealed that C1 is a Level 2, high-functioning individual and did not require constant supervision. In addition, C1 did not disclose any history of sexual assault allegedly committed by C2 and C3 to facility staff while in their care. Per facility staff and C2’s VCBH case manager, C2 did not have any history of sexually assaulting others. In addition, C3 also did not have a history of sexually assaulting clients at the facility, that staff were aware of. Both C2 and C3 denied that they committed sexual assault toward C1. Interviews with other residents did not express feeling unsafe or threatened around C2 or C3 and denied being sexually abused while in care. The evidence obtained from interviews and records suggests that there was no corroborating evidence to prove that C1 was sexually abused by C2 while in care.

Exit interview and copy of report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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