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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:19:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2022 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20221103145142
FACILITY NAME:COTTONWOOD, THEFACILITY NUMBER:
561702356
ADMINISTRATOR:FLORO CORTESFACILITY TYPE:
735
ADDRESS:1417 LIRIO AVENUETELEPHONE:
(805) 647-6046
CITY:SATICOYSTATE: CAZIP CODE:
93004
CAPACITY:24CENSUS: 24DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Floro CortesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff do not adequately manage client's behaviors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a complaint visit regarding above allegation. Upon arrival LPA met with Staff Marshall Sanjuan. Administrator was contacted by staff.

Beginning at 12pm LPA and staff toured the facility and interviewed random clients. LPA met with Administrator and discussed incident report dated 10/23/2022. Client #1 (C1) reported to staff that Client #2 tried to hit C1. Incident was reported to Administrator. Staff reported that C2 may be under the influence of an unknown substance. In discussing the incident with Administrator it was revealed that they are aware of C2's behavior and it has been an ongoing issue/concern. Administrator expressed that he has discussed C2's behavioral issues with Case Manager however it is still ongoing. Administrator stated it is difficult to manage clients behaviors and enforce house rules.
Based on the information gathered allegation is deemed substantiated at this time.
Following deficiencies issued and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. Copy of report provide to Administrator by email 11/9/22.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20221103145142
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision; (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by;
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The Administrator agreed to provide written plan of action explaining the steps the facility will take to control behavior issues and to assure that clients personal rights are not violated at the facility.
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Based on interview with Administrator - revealed that they are unable to deal with certain clients behavior and unable to enforce house rules on clients.

This poses an immediate health and safety risk to the clients 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2022 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20221103145142

FACILITY NAME:COTTONWOOD, THEFACILITY NUMBER:
561702356
ADMINISTRATOR:FLORO CORTESFACILITY TYPE:
735
ADDRESS:1417 LIRIO AVENUETELEPHONE:
(805) 647-6046
CITY:SATICOYSTATE: CAZIP CODE:
93004
CAPACITY:24CENSUS: 24DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Floro CortesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Food service is inadequate
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a complaint visit today regarding above allegation. Upon arrival LPA met with Staff Marshall Sanjuan. Administrator was contacted by staff.

Beginning at 12pm LPA and staff toured the facility and interviewed random clients. LPA and staff also toured that facility kitchen and pantry area. Facility food supply observed stocked with fresh fruits and vegetables; variety of meats; snacks and juice/water. LPA also Interviewed with ten (10) clients and all clients reported receiving snacks and three meals a day.

Based on the above information gathered, allegation "Food service is inadequate" is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report issued to Administrator(email 11/9/2022).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3