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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:06:39 PM

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
07/11/2024 and conducted by Evaluator Christine Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240711103141
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: 21DATE:
07/15/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Marcial San Juan, StaffTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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1. Staff does not ensure facility has adequate food supply.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and was let into the facility by Marcial San Juan, Staff. Floro Cortes Jr, Administrator was contacted by staff and he arrived at 12:31pm to participate in the visit but left during the visit. The reason for today's visit was explained.

On today's visit, LPA Yee conducted an interview withl Marcial San Juan, Staff at 11:40am, the Administrator at 12:41pm, Resident #1 at 1:32pm and Resident #2 at 1:36pm and toured the back building housing the facility's food supply at 12:14pm.

Per interviews conducted with Maricial San Juan, they have plenty of food. If they run low on food, he makes a list for the Administrator and he purchases the food. Per Marcial, they also recently received a donation of
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20240711103141
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: 07/15/2024
NARRATIVE
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vegetables from the person who does their CPR training. The vegetable donor also owns their own facility. The donated brussel sprouts and spaghetti squash were observed to be spoilt and were tossed by staff during the tour of the pantry.

Per tour of the back building used as the facility's pantry, LPA observed sufficient perishables such as ground beef, trays of chicken, hamburger patties, rounds of beef, turkey breasts, green beans, zucchini, cabbage, lettuce, turkey lunch meat, oranges, gallons of milk, spaghetti squash, grape tomatoes, a case of eggs, ground turkey, fish sticks, hot dog buns, frozen strawberries and packaged greens in the freezer and refrigerator for a minimum of 2 days. Per review of the non-perishable foods, LPA Yee observed, canned applesauces, containers of lemonade mix, a half a container of rice, a bag of butter milk pancake mix, 4 bags of cereal, cookies, cans of chicken noodle soup, cans of chicken broth, 2 bottle of ketchup, 2 bottles of yellow mustard, 3 large cans of corn hash, 2 large cans of Beef Ravioli, 2 large cans of marinara sauce, 4 large cans of tuna, 4 large cans of chili sauce with beans, 6 boxes of top ramen and cases of water. LPA Yee did not observe any cans of vegetables, pastas/noodles, potatoes, or other snacks except for cookies to allow for 3 snacks a day. Based on the ingredients and supplies observed in the pantry, the Administrator was asked to create 3 balanced meals a day and 3 snacks for 7 days for a capacity of 24 residents and he agreed, that there was insufficient non-perishable foods maintained on the premises to create the required meals and snacks to last for a minimum of seven days.

Based on the interviews conducted with Staff, Administrator and a tour of the back building serving as the facility's pantry, there is sufficient evidence to support the allegation that staff does not ensure facility has adequate food supply.

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

Exit interview was conducted, Appeals Rights were discussed and a copy was provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240711103141
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: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2024
Section Cited
CCR
85076(d)(1)
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Food Service: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement was not met as evidenced by: The facility pantry was observed to
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The Licensee will purchase additional non-perishable foods to allow for 3 balanced meals and 3 snacks for 7 days for the licensed capacity of 24 residents. Fax a copy of the receipt to Licensing by 7/16/24.
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have cans of chili, ravioli, chicken noodle soup, canned tuna, corn hash, marinara sauce but not in quantities to meet the one week requirement for non-perishable foods.
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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: 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
LIC9099 (FAS) - (06/04)
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