565801321-12-28-2023-29-AS-TCAA-CYXUF4-20231228143208

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 10/26/2023
Date Signed: 12/28/2023 02:33:00 PM

Document Has Been Signed on 12/28/2023 02:33 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 HOME		FACILITY NUMBER:	565801321
ADMINISTRATOR:	FLORO P CORTES JR		FACILITY TYPE:	735
ADDRESS:	316 WALNUT DRIVE		TELEPHONE:	(805) 485-3445
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY: 6		CENSUS: 5	DATE:	10/26/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Floro Cortes, Jr.		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced required annual continuation visit to the above facility. LPA met with the licensee/administrator Floro Cortes, Jr. and explained the reason
for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen. Cleaning supplies and items that could pose a danger were secured in locked cabinets. The facility has a supply of emergency food and water. The hot water temperature was measured at 134.5*F which is over the temperature range allowed of 105*F - 120*F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and

good condition. At the time of the visit, living room and dining room furniture appear to be in good condition. There is a covered patio and patio furniture for client use. The fire extinguishers appeared to be fully charged and were last inspected 10/24/2023. The smoke and carbon monoxide detectors were tested and functioned properly during the visit. Laundry is located outside in the secondary fenced backyard. Laundry soap is stored locked in the house but the administrator is planning on putting in a locked cabinet next to the laundry area to store chemicals in a more convenient location.

(continued on 809-D)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 565801321
	VISIT DATE: 10/26/2023

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(continued from 809)

RESTROOM: The facility has two restrooms. One restroom is primarily used by the clients. It was clean and sanitary with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature in the common hallway restroom measured at 132.9*F which is over the temperature range allowed of 105*F - 120*F.

MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the dining room. Medications appear to be given as prescribed. The facility utilizes medication administration records and centrally stored medication and destruction records.

RECORDS: Resident files reviewed were found to be complete. Two staff files were reviewed and found to be complete (some records were not printed but found on the computer). The file for staff 1 (S1) was missing from the facility. The administrator stated he may have taken it home to organize the file. There were some loose pages found in the administrator's office but some training records, including medication training, was missing. Disaster drills are conducted quarterly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file, however the disaster plan needs to be updated.

INTERVIEWS: Interviews were conducted with one staff and one client. No issues or concerns revealed.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided to the administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/28/2023 02:33 PM - It Cannot Be Edited

Created By: Teresa Camara On 10/26/2023 at 04:09 PM

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: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of two temperature readings (kitchen and client bathroom) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2023
	Plan of Correction
1 2 3 4	Licensee will turn down the temperature on the water heater and take readings for five days to ensure the temperature falls between 105F - 120F. Licensee will submit these readings to CCL on or before 11/2/2023.

Type B

Section Cited

CCR

80065(f)(4)

Personnel Requirements

(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out one staff records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2023
	Plan of Correction
1 2 3 4	Licensee will conduct medication training with Staff 1 and submit the training records to CCL on or before 11/2/2023.

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:

Desaree Perera

LICENSING EVALUATOR NAME:

Teresa Camara

LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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