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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609911
Report Date: 10/15/2024
Date Signed: 10/16/2024 08:15:43 AM


Document Has Been Signed on 10/16/2024 08:15 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, 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: 5DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Alexander Tecson, AdministratorTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the facility. LPA met with Alexander Tecson, Administrator and Amalia Davis, Assistant Administrator. LPA explained the purpose of the visit. The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there are five (5) residents residing in the facility. The facility has a fire clearance for six (6) non-ambulatory residents, of which six (6) can be bedridden, a hospice waiver for six (6) residents, and a dementia waiver for six residents.

Entrance Interview Conducted:
At the time of arrival, there four residents and four care staff including John Davis, Co-Administrator/Direct Care Staff, and Amalia Davis, Assistant Administrator/Direct Care Staff present in the facility. One resident is temporarily out of the facility due to receiving a higher level of care. Administrator Tecson stated he is present in the facility seven days a week approximately four hours each day.
The facility consists of a common area and office area, kitchen, and dining area. Leading off the living room are three private bedrooms (Bedrooms 1, 2, 3) and a bathroom off the hallway. Bedroom 2 has a private bathroom. There are two additional private bedrooms (Bedrooms 4 & 5) and a bathroom leading from another hallway off the common area. The bathrooms off the hallway are accessible to all residents in care. The private bathroom in Bedroom 2 is only accessed by the resident who resides in Bedroom 2. Each bedroom has exits to the backyard areas of the facility. The bathrooms have secure grab bars and no skid flooring.
The kitchen consists of refrigerator, built-in oven, stove top, microwave, coffee maker, rice maker, blender, toaster, dishwasher, water filter and a pressure cooker. Sharps are kept in a locked drawer located near the kitchen sink. Medications and First Aid kit are kept in a locked cabinet near the dining area. Medications and sharps are kept inaccessible to residents in care. The First Aid kit is complete.

Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024
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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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
VISIT DATE: 10/15/2024
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 The living room and dining area are furnished with adequate furnishings to sustain a capacity of six residents.
The facility maintains a comfortable room temperature. Residents’ records, personnel documents and records of confidentiality are kept in a locked closet in the common area.
The backyard consists of visitation areas including tables. chairs, umbrella, benches, concrete paved walkway with railing, potted plants, fruit trees, and other natural vegetation. A staff room, storage area and laundry room are located behind the main dwelling and are inaccessible to residents in care. Emergency food is kept in the locked storage area.
Residents may participate at will in various activities based on their individual interests and preferences. Residents are offered music entertainment in the facility, backyard walks, backyard activities consisting of games, rock painting, crocheting, playing musical instruments, and other activities of the residents’ choice. Excursions outside the facility include scenic drives, personal care appointments, special family recognition activities, and holiday celebrations.
There are seven smoke alarms and one carbon monoxide detector, and one hard wired pull alarm that alerts the local fire department.
Residents' records are up-to-date. Personnel records and staff trainings are current and up-to-date. All staff have been properly associated to the facility.
At approximately 2:00 pm, water temperatures were measured as follows: Kitchen sink faucet, 115.0 degrees Fahrenheit (F); Bathroom #1 at hallway, 114.3 degrees F; Bathroom #2 at hallway, 113.3 degrees F; and the private bathroom in Bedroom #2 measured at 115.1 degrees F.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety and personal accommodations.

The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on 8/6/2024.

Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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