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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:06:04 PM

Document Has Been Signed on 12/06/2024 05:06 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/
DIRECTOR:		FLORO P CORTES JRFACILITY TYPE:
735
ADDRESS:316 WALNUT DRIVETELEPHONE:
(805) 485-3445
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 4DATE:
12/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Floro CortesTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted a case management - incident visit. The LPA met with administrator Floro Cortes explained the reason for the visit.

This visit is regarding an incident which took place on 11/26/2024 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.

During today's visit the LPA reviewed and obtained pertinent records starting at 4:10 p.m., and conducted a brief facility tour. All of the current clients were at the facility.

On 12/05/2024, C1 moved to a different home.

Further investigation is needed regarding this incident. No citations were issued. Exit interview conducted and report emailed to administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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