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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 04/04/2024
Date Signed: 04/05/2024 08:24:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/04/2024 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20240404123523
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: 23DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Floro Cortes, Jr.TIME COMPLETED:
04:47 PM
ALLEGATION(S):
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Resident records were not kept confidential.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA initially met with house manager Marcial San Juan and explained the reason for the visit. The house manager then called the administrator Floro Cortes, Jr. who came to the facility to meet with LPA at 2:50 p.m.

At 2:20 p.m. LPA interviewed the house manager. At 2:41 p.m. LPA interviewed client 1 (C1). At 2:59 p.m. LPA interviewed client 2 (C2). At 3:07 p.m. LPA interviewed staff 1 (S1) by phone. 3:15 p.m. LPA reviewed video footage captured of visitors to the facility on 3/29/2024 at approximately 2:43 p.m. The video showed two visitors to the facility inquiring about a former client at the facility, client 3 (C3). The visitors were requesting information and to see the records for C3. The house manager explained they could not release C3's records to the visitors as they were not listed as family on the documents the facility held.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
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-20240404123523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
VISIT DATE: 04/04/2024
NARRATIVE
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(continued from LIC9099)

The house manager then contacted by text the administrator requesting the phone number for C3's responsible party. The administrator forwarded that information without knowledge that the house manager intended to pass that along to the visitors.

Witnesses confirmed they did not see the visitors go into the facility office where C3's records were stored. Staff confirmed that the office remains locked at all times and only the house manager and administrator have the keys.

Witnesses and staff confirmed the visitors did not remove anything from C3's former room. C3's former roommate indicated the visitors asked questions about C3's family and if C3 ever spoke about their family. Staff indicated the visitors asked similar questions of them as well.

Based on information obtained during interviews, staff provided visitors with C3's responsible party's phone number which should have been held confidential unless the responsible party approved the release of their number, which they did not. Therefore, the allegation "Resident records were not kept confidential" is 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 report and appeal rights were reviewed with administrator and a copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240404123523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: COTTONWOOD, THE
FACILITY NUMBER: 561702356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2024
Section Cited
CCR
80070(c)
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80070 Client Records (c) All information and records obtained from or regarding clients shall be confidential.

This requirement is not met as evidenced by:
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Administrator will conduct training with all staff regarding maintaining confidentiality of records and information of clients. Evidence of training will be forwarded to CCL on or before 4/11/2024.
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Based on interviews, the licensee did not comply with the above cited section, as confidential information from C3's records was released to an unknown visitor, which poses a potential health and safety 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: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3