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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801321
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:04:57 AM

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
07/28/2023 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230728132731
FACILITY NAME:CORTES ADULT FAMILY HOMEFACILITY NUMBER:
565801321
ADMINISTRATOR:CONSUELO CORTESFACILITY TYPE:
735
ADDRESS:316 WALNUT DRIVETELEPHONE:
(805) 485-3445
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:6CENSUS: 5DATE:
08/02/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Floro CortesTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff failed to seek medical attention for client in a timely manner
Facility failed to report incidents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation regarding the above noted allegations. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison.

Upon entry to the facility LPA and QAS met with staff 1 (S1) at 9:05 a.m. S1 called the licensee administrator Floro Cortes who arrived at the facility at 9:20 a.m. LPA explained the reason for the visit.


(continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
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-20230728132731
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: CORTES ADULT FAMILY HOME
FACILITY NUMBER: 565801321
VISIT DATE: 08/02/2023
NARRATIVE
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(continued from 9099)

At 9:08 a.m. LPA interviewed S1. At 9:21 a.m. LPA interviewed licensee. At 9:20 a.m. LPA reviewed records.

During LPA's visit, two clients were in day program, two clients were at the facility and one client was at a skilled nursing facility.

Licensee and S1 confirmed that client 1 (C1) had passed out or had a seizure and was unconscious for several minutes on the following dates: 7/6/2023, 7/17/2023, 7/24/2023, and 8/1/2023. Emergency services were called on 7/6/2023 and C1 was taken to the hospital. However, licensee and staff failed to call emergency services or seek medical assistance on 7/17/2023, 7/24/2023, and 8/1/2023. In addition, the licensee failed to report the 7/17/2023 and 7/24/2023 incidents to Community Care Licensing (CCL) as required. Licensee will report the 8/1/2023 incident by end of business today, 8/2/2023.

Based on the above noted information, the allegations “Staff failed to seek medication attention for client in a timely manner” and “Facility failed to report incidents” are both deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. A copy of the report and appeal rights were issued to the licensee.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230728132731
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: CORTES ADULT FAMILY HOME
FACILITY NUMBER: 565801321
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
80075(a)
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80075(a) Health Related Services. (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Licensee will train staff regarding contacting emergency services in the event of a medical emergency and what constitutes a medical emergency. Licensee will provide evidence of training to CCL on or before 8/4/2023.
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Based on interviews, the licensee did not comply with the section cited above as the licensee did not seek timely medical services when C1 passed out on three out four occasions, which poses an immediate health risk to persons in care.
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Type B
08/09/2023
Section Cited
CCR
80061(b)(1)(E)
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80061(b)(1)(E) Reporting Requirements. (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report... seven days...
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Licensee will train staff regarding reporting requirements and provide evidence of training to CCL on or before 8/9/2023. Licensee will also submit the late reports for incidents on 7/17/23 and 7/24/23 by 8/9/23.
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Based on interviews and record review, the licensee did not comply with the section cited above as the licensee did not report two incidents in which C1 passed out on two occasions, which poses a potential risk to persons 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3