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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 01/17/2025
Date Signed: 01/17/2025 06:19:15 PM

Document Has Been Signed on 01/17/2025 06:19 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:
01/17/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Floro Cortes Jr.TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek conducted a continuation of the required annual inspection (annual/random). LPAs met with licensee/administrator Floro Cortes and explained the reason for the visit.

During the previous visit on 1/10/2025, fire extinguishers were observed throughout the facility to be fully charged and last serviced 10/9/2024. Combination smoke detectors/carbon monoxide detectors throughout the facility were tested and were operational at the time of the visit.

Today, beginning at 10:15 a.m., LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: There are 12 (twelve) total bedrooms, all of which are shared rooms and all were observed during the facility tour. Client bedrooms appeared to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Renovations have started in building three (3); clients are still able to stay in their room at this time. Renovations will be conducted throughout the facility with a couple rooms requiring asbestos abatement and clients to relocate to other vacant rooms during the work. LPAs collected information about the renovations that will be taking place.

RESTROOMS: Client restrooms were observed to contain sufficient amounts of soap and paper products in each restroom. One restroom in building four (4) is not available for use as renovations are being done. Hot water temperature was measured at 116.4*F.

(continued on LIC809-C, page 2)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 7
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: 01/17/2025
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(continued from LIC809, page 1)

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, dining room furniture was observed to be in adequate condition. The temperature was maintained at a comfortable level throughout today's visit.

KITCHEN: LPAs observed the kitchen/dining area. Kitchen appliances appear to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including an emergency supply of water. All knives and cleaning supplies were observed to be locked and stored in compliance with regulation.

OUTDOOR SPACE: The outdoor area has shaded outdoor seating areas equipped with furniture for client use. There were no bodies of water noted.

RECORD REVIEW: LPAs reviewed four (4) staff and ten (10) client records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, client physician's report, needs and service appraisals, and admission agreements. Staff 1 (S1) was missing their health screening. Client 1 (C1) was missing a medical assessment and needs and services plan.

MEDICATION REVIEW: Medications for three (3) clients were reviewed. Medications were observed to be properly documented and in compliance at the time of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPAs reviewed the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. LPAs also reviewed the facility's emergency disaster plan folder, however it was missing required details at it was not documented on the proper form LIC610E. Disaster drills are conducted monthly.

INTERVIEWS: Throughout today’s visit, LPAs interviewed staff and clients.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Licensee/Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 06:19 PM - It Cannot Be Edited


Created By: Teresa Camara On 01/17/2025 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of four which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Licensee will have S1 obtain a health screening with TB test and submit evidence to CCL on or before 1/28/2025.
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of ten clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Licensee will obtain a medical assessment and complete a needs and services plan for client 1 (C1) by 1/28/2025 and provide evidence to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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