565801321-10-30-2024-29-AS-EMOY-DAJTYG-20241030150843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:10:08 PM

Document Has Been Signed on 10/30/2024 03:10 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/ DIRECTOR:	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: 4	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Herminia Anaen - Staff Nicole Mayernik - Satff		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. The entrance to the facility is on the side of the home. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator was not available to attend and designated staff to sign. The LPA met with staff / caregivers Herminia Anaen and Nicole Mayernik and explained the reason for the visit. The LPA 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 two (2) day perishable and seven (7) day 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 114.4.F at 10:26 a.m. which is within the required range.

COMMON SPACES/ BACKYARD: 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. The fire extinguishers appeared to be fully charged and were last inspected 10/09/2024. The smoke and carbon monoxide detectors were tested at 11:41a.m and functioned properly during the visit. The last emergency disaster drill took place on 08/06/2024 and conducted quarterly. Activities were observed in the common areas. Laundry is located outside in the secondary fenced backyard. Laundry soap is stored in a locked cabinet next to the laundry area. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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 10/30/2024 03:10 PM - It Cannot Be Edited

Created By: Erica Mosley On 10/30/2024 at 02:47 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(e)

Personnel Records

(e) All personnel records shall be maintained at the facility site. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in two (2) out of three (3) staff files were not available which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee agrees to send CCLD / LPA proof of staff files in scanned / email format with all the required documents.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Erica Mosley

LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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: 10/30/2024

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Report Continued from LIC 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 106.1 F at 10:20 a.m. which is in the required range.

BEDROOMS: There are three (3) client bedrooms; all double-occupancy, however one (1) space is vacant at the time of the visit. LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There was a linen closet in the hallway with extra towels and linens. There is one (1) staff room that remains locked at all times.

MEDICATIONS: Medications review began at approximately 11:51 a.m. The medications are locked in a cabinet adjacent to the kitchen. Medications for four (4) clients were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.

RECORDS: The LPA and staff reviewed P&I money at 2:15 p.m. for three (3) clients. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash.

Resident Records were reviewed beginning at 10:50 a.m. and personnel records at 11:37 a.m. four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued to LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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: 10/30/2024

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Report Continued from LIC 809C...

One (1) personnel file was reviewed, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Two (2) other files including the administrators were attempted however the files were with the administrator and not available at the time of the visit which poses a potential health, safety or personal rights risk to persons in care.

INTERVIEWS: One (1) staff interviews were conducted. There were no clients available for interview during the inspection.

Documents were not available at the time of the visit and will be emailed to the LPA. Resident Roster LIC 9020, Staff Roster LIC 500, and Surety bond. Liability Insurance was sent to LPA during the visit.

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.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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