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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 12/27/2023
Date Signed: 12/28/2023 08:13:43 AM

Document Has Been Signed on 12/28/2023 08:13 AM - 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:FLORO P CORTES JRFACILITY TYPE:
735
ADDRESS:1417 LIRIO AVENUETELEPHONE:
(805) 647-6046
CITY:SATICOYSTATE: CAZIP CODE:
93004
CAPACITY: 24CENSUS: 24DATE:
12/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Marcial San JuanTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced case management visit due to deficiencies noted during today's complaint investigation visit (complaint control number 29-AS-20231226134000). Upon arrival there were two caregivers present. LPA spoke with administrator Floro Cortes Jr. over the phone. He was out of the area and could not meet with LPA. LPA explained the allegations and reason for the visit. The administrator authorized the facility manager Marcial San Juan to sign the report. The facility manager arrived at the facility at 2:30 p.m.

During today's visit, LPA interviewed the facility manager regarding Client 2 (C2) not taking their medication. The facility manager confirmed that C2 will take the medications, put them in their mouth but sometimes will spit them out without staff's knowledge but then later staff will find medications under C2's bed, floating in the toilet or outside by the trees. Last night, 12/26/2023, the facility manager recalled C2 put the medications in their mouth and then got up and went to the bathroom to "throw up". The facility manager observed C2 spit out the medications into the toilet.

The facility manager stated they have notified C2's caseworker on multiple occasions and even sent photos of the medications they have found. It is his understanding the caseworker is trying to locate a higher level care facility for C2. The facility manager stated they write down in a log book when they are aware C2 has spit out their medications and he notifies the administrator but he does not know if the administrator reported these incidents to CCL. There is no record of these incidents being reported to CCL as required.

Per California Code of Regulations (CCR), Title 22, see LIC 809-D for deficiencies cited. Exit interview conducted. A copy of the report was issued, along with appeal rights.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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Document Has Been Signed on 12/28/2023 08:13 AM - It Cannot Be Edited


Created By: Teresa Camara On 12/27/2023 at 04:11 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: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days
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Licensee will reviewe reporting requirements with staff and provide evidence of training to CCL on or before 1/5/2023.
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of the occurrence of any of the events specified in (A) through (D) below.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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This requirement was not met as evidenced by: Based on interviews with the facility manager, C2 has been spitting out their medications, this has not been reported to CCL, which poses a potential health and safety risk to residents in care.

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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: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
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