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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 03:43:29 PM

Document Has Been Signed on 09/04/2024 03:43 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/
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 case management - incident visit regarding a self reported incident which took place on 7/25/2024. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Katy Robison. LPA and QAS met with administrator Floro Cortes and explained the reason for the visit.

Upon arrival to the facility LPA and QAS were met by the house manager Marcial San Juan who called the administrator. The administrator arrived at approximately 2:25 p.m. LPA and QAS interviewed the administrator. At 2:45 p.m. LPA reviewed and obtained pertinent records. At 3:06 p.m. LPA and QAS inspected the shared room of client 1 (C1) and client 2 (C2). LPA and QAS briefly spoke with C2.

The administrator stated C1 was last seen at the facility on 7/25/2024. C1's physician's report states they can leave the facility without supervision. C1 frequently leaves the facility for extended periods of time but this is the longest C1 has been gone; he has still not returned. A missing persons report was filed with the police.

Further investigation is needed. Exit interview conducted. Copy of report issued.
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)
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