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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609911
Report Date: 10/26/2021
Date Signed: 10/26/2021 04:27:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BUTTERFLY INN, LLC, THEFACILITY NUMBER:
567609911
ADMINISTRATOR:TECSON, ALEXANDER MFACILITY TYPE:
740
ADDRESS:4370 WHITTIER COURTTELEPHONE:
(805) 676-1909
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Alexander TecsonTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection. LPA met with Administrator Alexander Tecson.

During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted. Hot water temperature read at 114.6 degrees F. in resident bathroom. PPE supplies were observed. LPA observed fire extinguishers fully charged. The smoke alarms and carbon monoxide detector were tested and were operable. Outdoor area toured- passageways are free of obstruction.

During facility tour starting at 3:01 pm with Administrator LPA observed potassium chor tabs, duloxetin capsules, metoprolol tablets, levetiracetam tablets, calcium and vitamin D3, vitamin B12, omega fatty acid soft gels, probiotic chewables and cranberry capsules in an unlocked dining room cabinet accessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BUTTERFLY INN, LLC, THE
FACILITY NUMBER: 567609911
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as resident medications were accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Administrator placed medication in a locked closet during facility visit. Administrator stated that they will provide documentation of scheduled staff medication training to CCL by 10/27/21. Administrator will provide documentation of staff training to CCL by 11/5/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021
LIC809 (FAS) - (06/04)
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