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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 02/04/2025
Date Signed: 02/05/2025 12:38:35 PM

Document Has Been Signed on 02/05/2025 12:38 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: 20DATE:
02/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:12 AM
MET WITH:Floro Cortes, Jr.TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced case management - incident visit regarding a death at the facility on 2/4/2025. LPA met with licensee/administrator Floro Cortes, Jr. and explained the reason for the visit.

LPA arrived at the facility at 10:12 a.m. Upon arrival LPA observed a Ventura County Sheriff's Department vehicle and a black mortuary van at the facility. At 10:24 a.m. LPA spoke with the Sheriff's Deputies. Deputy Furubotten stated there were no signs of foul plan in Resident 1's (R1) room. In addition, based on R1's medical history and continued smoking, the coroner declined receiving R1's remains and indicated based on the information R1's death appeared to be due natural causes. Deputy Furubotten gave LPA a card with the incident number and name of the mortuary where R1's remains would be taken. Deputy Furubotten stated R1's family chose the mortuary.

Starting at 10:47 a.m. LPA reviewed R1's records, including medical notes regarding R1's medical condition, and obtained copies of records. At 11:39 a.m. LPA interviewed Staff 1 (S1) who was the staff that last spoke with R1 at approximately 9:00 p.m. on 2/3/2025. S1 stated R1 was laying in bed and sat up in bed to take R1's bedtime medications. R1 was talking and acting normal that evening. The night shift staff, Staff 2 (S2), starts work at 11:00 p.m. and walks around the facility a couple times during their shift but does not enter the rooms. S2 peaks inside the rooms through windows or the door. The residents do not require hands on care.

At approximately 6:30 a.m. on 2/4/2025, Staff 2 (S2) went to check on R1 as R1 normally would get up early for breakfast. That is when S2 discovered R1 was non-responsive and S2 called 9-1-1. S2 called the licensee at 6:50 a.m. after calling 9-1-1. The licensee stated he called R1's family/authorized representative at 8:30 a.m. and called R1's Ventura County Behavioral Health caseworker at 8:45 a.m.

No deficiencies were observed. Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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