567609911-4-28-2025-29-AS-KLOZ-DG93KM-20250430181922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609911
Report Date: 04/28/2025
Date Signed: 04/28/2025 10:35:53 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2025 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20250207100126

FACILITY NAME:	BUTTERFLY INN, LLC, THE		FACILITY NUMBER:	567609911
ADMINISTRATOR:	TECSON, ALEXANDER M		FACILITY TYPE:	740
ADDRESS:	4370 WHITTIER COURT		TELEPHONE:	(805) 676-1909
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 4	DATE:	04/28/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Alexander Tecson / Miguel Lopez		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff did not meet residents’ oxygen needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial complaint visit was conducted on 02/13/2025 by LPA Esther Cortez. On today's visit, LPA Arroyo met with staff, Miguel Lopez as the Administrator was unable to come to the facility, however gave staff permissionto sign report. Entrance interview.

During the initial visit on 02/13/2025, LPA Cortez conducted a plant tour, conducted interviews with the Administrator, three staff and one resident, and obtained copies of pertinent documents between 3:45 p.m. and 4:45 p.m.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250207100126

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/28/2025

NARRATIVE

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Report Continued from LIC 9099...

It was alleged that staff did not meet resident’s oxygen needs. It was reported that Resident #1 (R1) was observed with low oxygen levels, and R1’s oxygen machine was used to restore their oxygen levels to normal. However, facility staff were instructed to turn off the oxygen machine to conserve electricity. Records reviewed and interviews conducted revealed that R1 was admitted to hospice care on 05/20/2023, with a primary diagnosis of Alzheimer’s disease and secondary diagnoses of hypertension and depression. According to the hospice care plan dated 05/20/2023, the doctor’s orders included the use of a nebulizer and oxygen concentrator at 5L as needed for shortness of breath or wheezing. Interviews further revealed that R1’s oxygen and pulse levels are frequently monitored throughout the day. If the oximeter indicates that R1’s oxygen levels fall below 90%, staff are instructed to turn on R1’s oxygen machine. However, if the oximeter reads 100%, the oxygen machine is turned off to maintain R1’s safety. Additionally, all four staff members interviewed denied turning off R1’s oxygen when needed or advising another staff member to turn off the oxygen while in use. Furthermore, during an interview with a resident, resident denied being refused assistance or medications by facility staff, stating they had no concerns and were receiving great care. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “staff did not meet resident’s oxygen needs”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC9099 (FAS) - (06/04)

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