<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561702356
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:09:37 PM

Document Has Been Signed on 07/15/2024 04:09 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:
07/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:51 PM
MET WITH:Marcial San Juan, StaffTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit due to deficiency noted during a visit conducted at the facility today. The reason for today's visit was explained.

On today's visit, interviews were conducted regarding the food supply, meal times and snacks at the facility.
Per information provided during the interviews by staff, breakfast is served at 5am-6pm, lunch is served at 10:30am-11am and dinner is served at 3:30-4pm. The reason provided for the early meal times is that the residents are hungry and are already standing in line and if the meals are ready, the residents can eat early. The residents also have access to apples and oranges throughout the day. Per staff, the only snack that the residents receive are at 5pm. They get cookies and coffee. Per interview with the Administrator, he indicated that the residents get 2 snacks. One snack is provided at 4pm, before dinner and one at 8pm. Per interviews conducted with Resident #1 and Resident #2, they get cookies and coffee after dinner at 5pm.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted with Marcial San Juan, Appeals rights discussed and a copy was given.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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 2
Document Has Been Signed on 07/15/2024 04:09 PM - It Cannot Be Edited


Created By: Christine Yee On 07/15/2024 at 03:33 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: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2024
Section Cited
CCR
80076(a)(4)

1
2
3
4
5
6
7
(a) In facilities providing meals to clients, the following shall apply: 4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.
This requirement was not met as evidenced by: The clients are not
1
2
3
4
5
6
7
The Licensee will provide a written action plan to clearly define when breakfast, lunch and dinner is provided and when the 3 snacks will be provided. The 3 snacks and type of snack to be provided will be included in the facility's menu. Licensee will provide an updated copy of the facility menu to Licensing by 7/23/24
8
9
10
11
12
13
14
provided with snacks in between breakfast, lunch and dinner. The only snack of cookie and coffee is provided after dinner.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2