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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 01/07/2025
Date Signed: 01/07/2025 11:09:38 AM

Document Has Been Signed on 01/07/2025 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CORTES ADULT FAMILY HOMEFACILITY NUMBER:
565801321
ADMINISTRATOR/
DIRECTOR:		FLORO P CORTES JRFACILITY TYPE:
735
ADDRESS:316 WALNUT DRIVETELEPHONE:
(805) 485-3445
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 4DATE:
01/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Floro CortesTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted a case management - incident visit. The LPA met with staff Angela Blue-Heil and explained the reason for the visit. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Katy Robison. Administrator Floro Cortes arrived during the visit at approximately 10:00 a.m. and was explained the reason for the visit. This visit is regarding an incident which took place on 11/26/2024 between client 1 (C1) and client 2 (C2).

During today's visit the LPA and QAS interviewed C2 and the Administrator.

On 12/05/2024, the Administrator called the regional office (RO), spoke to the officer of the day and self reported that C1 disclosed they were inappropriately touched by C2. On the same day, the Administrator was advised to submit an incident report and SOC341 by LPA Cortez. The incident report and SOC341 documented that on 11/26/2024, C1 was very upset and was talking out loud to themselves, and they stated that they were touched inappropriately from behind on their back and buttocks by C2. Staff 1 (S1) heard C1 talking out loud and asked them what happened, C1 said they were touched by C2, however the Administrator was not aware of the incident until December 5th, 2024. On 12/05/2024, C1 moved to a different home.

Throughout the investigation, interviews were conducted with C1, C2 as well as with S1. C2 denied to engaging in sexual touching with C1 during the interview process and disclosed that C1 touched them. S1 did not observe the alleged incident. The Administrator, revealed that they reported to CCLD, ombudsman and local law enforcement on 12/06/2024. However, staff failed to report the incident to Community Care Licensing (CCL) in a timely manner.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted, appeal rights provided, a copy of this report issue.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/07/2025 11:09 AM - It Cannot Be Edited


Created By: Esther Cortez On 01/07/2025 at 10:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CORTES ADULT FAMILY HOME
FACILITY NUMBER: 565801321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
80061(d)

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80061(d)Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman,.. licensing agency, and the local law enforcement agency within 24 hrs. This requirement is not met as evidence by:
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The licensee agreed that all staff, including the administrator shall obtain training from an outside vendor regarding Mandated Reporting and CCLD reporting requirements in accordance with 80061. Proof shall be submitted to CCLD by 1/17/2025. Licensee will also submit LIC500.
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Based on interview with Administrator and S1, it was revealed that an incident alleging abuse was not reported accordingly as required. Alleged incident of abuse was discovered on 11/26/2024 and was reported to CCLD on 12/5/2024.
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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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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