<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603661
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:00:52 AM


Document Has Been Signed on 01/20/2023 11:00 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:BUTTERFLY GARDENS IIFACILITY NUMBER:
374603661
ADMINISTRATOR:LEO ESPINOSAFACILITY TYPE:
740
ADDRESS:5557 SOLEDAD MOUNTAIN ROADTELEPHONE:
(858) 764-4442
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 6DATE:
01/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Licensee, Leo EspinosaTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced case management visit at the facility. LPA was greeted at the front entrance by Caregiver, Samanta Galila and granted entry after identifying herself. LPA met with Licensee, Leo Espinosa and explained the purpose of the visit which was related to a complaint investigation.

During this visit, LPA reviewed resident 1’s (R1 – See LIC 811 Confidential Names List) Physician’s Report and Care Plan with Licensee. LPA reviewed Title 22, Division 6, Chapter 8, Article 12, Dementia, Section 8705, Care of Persons with Dementia with Licensee. LPA advised the Licensee Physician’s Reports needed to be conducted annually or sooner if there is a change and dated. LPA further advised Licensee that a reappraisal, or observation indicates that the residents care needs have changed, corresponding changes shall be made in the care plan for that resident and signed and dated. Technical Advisory given.

An exit interview was conducted with Licensee and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1