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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 04/26/2023
Date Signed: 10/09/2023 12:33:15 PM

Document Has Been Signed on 10/09/2023 12:33 PM - 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:CONSUELO CORTESFACILITY TYPE:
735
ADDRESS:316 WALNUT DRIVETELEPHONE:
(805) 485-3445
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 5DATE:
04/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Floro CortesTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison. LPA and QAS met with staff 1 (S1) and the administrator Floro Cortes arrived to the facility at 8:55 a.m. LPA explained the reason for the visit.

This visit is regarding an incident which took place on 4/14/2023 between client 1 (C1) and client 2 (C2). The investigation regarding the incident will be conducted by Community Care Licensing Investigations Branch. An investigator will return at a later date to conduct the investigation.

LPA conducted a brief facility tour at 8:25 a.m. All clients except C1 were in day program.

LPA reviewed and obtained pertinent records starting at 8:35 a.m.

Further investigation is needed regarding this incident. No citations were issued. Exit interview conducted and report emailed to administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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