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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561702356
Report Date: 12/10/2024
Date Signed: 12/11/2024 08:17:33 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
12/03/2024 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20241203231633
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:
12/10/2024
UNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Floro CortesTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility does not have adequate staff to meet the needs of the residents.
Facility is in disrepair.
Facility is unsanitary and unkempt.
Facility is malodorous.
Staff does not ensure that the facility is free of hazards for the residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA initially met with the facility house manager and explained the reason for the visit. Licensee/administrator Floro Cortes arrived approximately 25 minutes later.

LPA interviewed the administrator starting at 12:51 p.m. and toured the facility at 2:52 p.m.

Regarding the allegation facility does not have adequate staff to meet the needs of the residents: LPA reviewed the needs of the residents with the administrator. There are no residents who require hands on care, incontinence care, bathing, or dressing. All of the residents are able to leave the facility unassisted by staff, although the house manager does take residents to medical appointments when necessary. Most of the residents at the facility are fairly independent. LPA reviewed the staff schedule with the administrator.

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

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 5
Control Number 29-AS-20241203231633
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: 12/10/2024
NARRATIVE
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(continued from LIC9099)


Regarding the allegation facility does not have adequate staff to meet the needs of the residents (continued): During the morning and afternoon there are usually three staff working. They recently had a staff quit and the administrator has someone they are interested in hiring. Currently, due to the loss of the staff who quit, during the morning and afternoon shift on Saturdays and Sundays there is only one person working; the house manager. The administrator stated he is available 24/7 if he is needed at the facility. However, it does not appear there is sufficient staffing, particularly on the weekends. Therefore, this allegation is deemed Substantiated at this time.

Regarding the allegation the facility is malodorous:
This allegation was regarding residents smoking cigarettes and marijuana in their rooms. The facility's house rules state residents are not allowed to smoke inside the buildings. There is a designated smoking area outside by the large tree. The administrator stated they have a very difficult time with some of the residents defying house rules and smoking in their rooms. He stated the staff will tell them they cannot smoke in the rooms, the residents will go outside and smoke for a period of time but then go back to smoking inside again. LPA observed one resident room in building one which was full of cigarette smoke. Based on the interview with the administrator and LPA observation, this allegation is deemed Substantiated at this time.

Regarding the allegations the facility is in disrepair and the facility is unsanitary and unkempt:
LPA observed chips, cracks and missing flooring materials in all of the buildings. LPA observed the main bathroom in building one had rust around the fixtures, the bath tub/shower was stained and in poor condition, and the flooring was in disrepair. The administrator stated the facility has received a grant to refurbish all of the buildings which will include plumbing, bathroom fixtures, flooring, painting and roofing. According to the project manager for the construction company who has been working with the County of Ventura to ensure permits will be issued, the work will soon be starting on buildings three, four, and five.


(continued on page 3, LIC9099-C)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20241203231633
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: 12/10/2024
NARRATIVE
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(continued from page 2, LIC9099-C)


Regarding the allegation staff does not ensure that the facility is free of hazards for the residents in care:
This allegation was regarding trip hazards from loose rugs in the facility. LPA observed the area rug in one of the dining rooms has turned up corners which presents a tripping hazard. Based on this observation, this allegation 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: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20241203231633
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: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
80072(a)(2)
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Personal Rights (a)(2)... each client shall have personal rights which include, but not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Licensee will issue written warnings to all residents who continue to break the rules and smoke in their rooms. Licensee has hired a contractor and received a grant to repair the facility. Evidence of both will be provided to CCL by 12/17/2024.
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Based on interviews and observations, the licensee did not comply with the above cited section, as residents were observed smoking in their rooms and the facility has flooring and bathrooms in disrepair, which poses a potential health and safety risk to residents in care.
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Type B
12/17/2024
Section Cited
CCR
80087(b)(1)
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80087 Buildings and Grounds (b) All clients shall be protected against hazards within the facility through provision of the following:
(1) Protective devices including but not limited to nonslip material on rugs. This requirement was not met as evidenced by:
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Licensee will have the area rug secured with nonslip materials and provide evidence of this repair to CCL on or before 12/17/2024.
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Based on observations, the licensee did not comply with the above cited section, as the area rug in the dining room was observed to have turned up corners creating a tripping hazard, which poses a potential health and safety risk to residents 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: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20241203231633
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: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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Licensee will provide CCL with an updated LIC500 personnel report showing sufficient staffing coverage for all days of the week. This will be provided to CCL on or before 12/17/2024.
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Based on interviews and review of staff schedule, there is only one person working during the day on the weekends, which poses a potential health and safety risk to residents 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: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5