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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 10/20/2023
Date Signed: 12/28/2023 02:31:41 PM

Document Has Been Signed on 12/28/2023 02:31 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:
10/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Floro Cortes Jr.TIME COMPLETED:
10:02 AM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit. LPA met with the licensee/administrator Floro Cortes Jr. and explained the reason for the visit. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Katy Robison.

This visit is regarding an incident which took place on 10/09/2023 between client 1 (C1) and client 2 (C2).

LPA and QAS interviewed the administrator starting at 8:40 a.m. regarding the efforts being made to ensure the safety of residents at the facility. The administrator stated he has moved clients around after having a discussion with them; they all agreed to the new room assignments. C2 no longer has a roommate. Staff are ensuring that C2 keeps their distance from other clients.

Administrator has a meeting coming up with C2's service coordinator and responsible party to address concerns regarding C2's behaviors. Administrator will discuss with the service coordinator setting up behavioral counseling for C2.

During the visit, LPA met a new staff member. In addition, the administrator stated that another staff has an appointment scheduled to take the administrator exam. Once that staff member has passed the administrator exam he will submit paperwork so they can become the administrator of the licensee's other facility in Oxnard which will free up some time for him to be at his other two facilities. He also intends to find a back-up administrator for his facilities.

No deficiencies observed. 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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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