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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:11:45 PM

Document Has Been Signed on 10/16/2023 04:11 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:FLORO P CORTES JRFACILITY TYPE:
735
ADDRESS:316 WALNUT DRIVETELEPHONE:
(805) 485-3445
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 5DATE:
10/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Floro CortesTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit. LPA met with the licensee/administrator Floro Cortes and explained the reason for the visit.

This visit is regarding an incident which took place on 10/09/2023 between client 1 (C1) and client 2 (C2). This incident has been referred to the Community Care Licensing Investigations Branch for review. An investigator or the LPA will return at a later date to conduct the investigation.

LPA reviewed and obtained pertinent records at 3:01 p.m.

LPA conducted a brief facility tour at 3:20 p.m. All of the clients were at the facility except Client 5 (C5) who went to a medical appointment.

After the incident on 10/09/2023, C1 moved to a different room. C2 no longer has a roommate. Client 3 (C3) remained in their room. C5 moved to share the room with C3. Client 4 (C4) remained in their room and now share it with C1.

Further investigation is needed regarding this incident. No citations were issued. Exit interview conducted and report emailed to administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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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