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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:27:17 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
05/15/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20230515150035
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: 23DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Marshall San JuanTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff are not properly addressing pest infestation in facility
Staff did not safeguard resident’s belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint investigation for the allegations listed above. LPA arrived at the facility at 01:08PM and met with facility staff Marshall Sanjuan. Licensee Floro Cortes was not available during today's visit. Entrance interview conducted.

During today's visit, LPA interviewed facility staff at 01:10PM, toured the facility with staff at 01:14PM, interviewed clients and took photographs throughout the visit. Licensee was contacted and provided LPA a copy of a recent pest control invoice.

The facility consists of 5 separate buildings. LPA observed all client rooms in each building throughout the facility. LPA observed rodent droppings and evidence of rodent infestation in all 5 of 5 buildings observed. Interviews revealed that residents see rodents daily, can hear rodents scurrying about at night, and have observed their belongings to have rodent damage. Staff interview revealed that the facility has regular pest
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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-20230515150035
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
VISIT DATE: 05/17/2023
NARRATIVE
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control, including weekly service. LPA did observe the monthly invoice as well as outdoor rodent traps around the south/southwest side of the facility property. Additionally, staff have provided sticky traps for client use. One sticky trap found during the facility tour contained a deceased rodent. Additionally, LPA and facility staff observed many holes in facility walls and floors throughout the buildings where rodents can enter the client rooms. Based on observation and interview, the allegations that "staff are not properly addressing pest infestation in facility" and "Staff did not safeguard resident’s belongings" are deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview was conducted. Today's reports and appeal rights were reviewed with facility staff and LPA provided a copy during the visit.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230515150035
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: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2023
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Facility staff did have rooms cleaned during today's visit. Proof of rodent droppings cleaned, holes in floor, walls, door to be provided to CCL by POC due date.
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Based on interview and observation, the licensee did not comply with the above cited section, as client rooms were observed to have rodent droppings and holes in walls, doors, and floors, which poses an immediate health and safety risk to clients in care.
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Type B
05/31/2023
Section Cited
CCR
80026(b)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (b) If such a client is accepted for or maintained in care, his/her cash resources, personal property...shall be safeguarded..in (c) through (n) below.
This requirement is not met as evidenced by:
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Facility staff indicated all client personal items with rodent damage would be discussed with clients' responsible parties and CCL will be updated with a plan to ensure all personal items are safeguarded by POC due date.
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Based on observation and interview, the licensee did not comply with the above cited section, as clients' personal belongings were observed with rodent damage, which poses a potential personal rights risk to 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
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