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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609799
Report Date: 05/22/2026
Date Signed: 05/22/2026 12:57:45 PM

Document Has Been Signed on 05/22/2026 12:57 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:CONNIE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
567609799
ADMINISTRATOR/
DIRECTOR:		NICOLE CORTESFACILITY TYPE:
735
ADDRESS:614 E NECTARINE STTELEPHONE:
(805) 240-2188
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
05/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Nicole CortesTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melisa Rankin arrived at the facility unannounced to conduct a required annual visit. At 8:32 a.m., the LPA arrived at the facility and spoke with the Administrator, Nicole Cortes and explained the reason for the visit. At 9:44 a.m., Licensee, Floro Cortes Jr the Licensee arrived at the facility. The facility is vendored by Tri-Counties Regional Center as a level 2 home.

LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Facility is a single-story residence that consists of four (4) client bedrooms, and two (2) bathrooms.

KITCHEN: The LPA observed the kitchen and dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives are stored and inaccessible to clients. Cleaning solutions and chemicals are inaccessible and locked away in a cabinet.

BEDROOMS: The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Client restrooms are clean and sanitary and in operating condition. Hot water temperature measured at 114.4 and 116.8 -degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: The LPA observed the back patio. The laundry units are located in the locked laundry room. Side gate was viewed, unlocked and pathways are cleared. Continued on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/22/2026 12:57 PM - It Cannot Be Edited


Created By: Melisa Rankin On 05/22/2026 at 12:29 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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in four out of four clients did not have 12 months of Centrally Stored Medication and Destruction records (CSMDR), and 3 medictations were not documented on the current CSMDR forms which poses a potential health and safety risk to persons in care.
POC Due Date: 06/12/2026
Plan of Correction
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Facility will located their current files of CSMDR and send LPA copies for each client of at least 2 months of records from June and July of 2025 or the facility will contact the pharmacy to obtain new copies of the past 12 months of medication.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that the posted Emergency Diaster form is out dated, the revised required 9 page diaster form was not completed as requested on a Technical Violation given from annual in 2025 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
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Facility will email LPA copy of the complete Emergency Diaster Plan by 5/26/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799
VISIT DATE: 05/22/2026
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Updated patio furniture with shade is being purchased, damaged by recent winds, but the garage was observed with table, rugs and is clean an usable for clients in care. The garage is detached to the house and remains locked when not used. Emergency water is located inside the garage.

COMMON AREAS: The LPA observed common area to be clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last serviced on 9/23/2025. Fire alarms/carbon monoxide detectors were tested and functioned properly at time of visit. Facility telephone was observed during the time of the visit.

RECORD REVIEW: LPA conducted a file review for all four (4) clients and five (5) staff and observed the following: Staff have first aid/CPR certificates and annual training completed. Client records were reviewed for but not limited to current Individual Programming Plan (IPP), medical records, P & I funds, admissions agreement, and consent forms. Files reviewed were complete. The last fire drill took place on 04/2026. Administrator’s Certificate is in the process of being renewed, Licensee’s Administrator Certificate expires 11/5/26.

LPA conducted a review of medication and medication documentation with the Administrator. LPA observed Medication Administration Records (MARs) for current month only. Facility obtains Centrally Stored Medication and Destruction Records (CSMDR) from the pharmacy, LPA observed 3 medications not noted on a CSMDR. LPA stated that the state CSMDR blank form can be printed and that all medication must be documented on the CSMDR, the responsibility is the facilities, not a pharmacy. CSMDR was for current month only. Licensee believes the records were pulled for archive and are located elsewhere. Due to the records note being on site and they did not have all medications recorded on the CSMDR, and the LPA’s inability to review the required 12 month documentation of the CSMDR, citation given.

DISASTER AND EMERGENCY RECORD: Facility received a technical violation in the prior annual regarding having a documented Emergency and Disaster Plan. Facility as of visit today did not have a complete Emergency and Disaster Plan. Licensee began the process of completing the required document, but due to the prior year notification not being adhered to, citation given.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC809 (FAS) - (06/04)
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