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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609799
Report Date: 12/13/2024
Date Signed: 12/13/2024 10:14:41 AM

Document Has Been Signed on 12/13/2024 10:14 AM - 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:CONNIE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
567609799
ADMINISTRATOR/
DIRECTOR:		FLORO CORTESFACILITY TYPE:
735
ADDRESS:614 E NECTARINE STTELEPHONE:
(805) 240-2188
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
12/13/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Trinida Valdez-StaffTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Esther Cortez conducted a case management - Collateral visit. LPA met with staff Trinidad Valdez and explained the reason for the visit. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Katy Robison. Administrator Nicole Cortes was notified via a phone call and explained the reason of the visit. The Administrator was unable to be at the facility during today's visit and designated staff Trinidad Valdez to review and sign the report.

This visit is regarding an incident which took place on 11/26/2024 between client 1 (C1) and client 2 (C2).

During today's visit the LPA and QAS met with Client 1 (C1) to discuss an the incident that occurred at their prior facility Cortes Family Home.


No deficiencies observed. No citations were issued. Exit interview conducted and report provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2024
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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