567609911-10-6-2023-29-AS-ECOZ-CWCQAR-20231006120023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609911
Report Date: 10/06/2023
Date Signed: 10/06/2023 12:00:55 PM

Document Has Been Signed on 10/06/2023 12:00 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:	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: 5	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Emma Carranza-Caregiver		TIME COMPLETED:	12:00 PM

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 Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 08:15 a.m. When the LPA arrived, there was two staff and five clients present. The LPA was greeted by Staff Emma Carranza and informed them of the reason for the visit. Administrator Alexander Tecson was unable to be present during todays visit and authorized staff Amelia Davis who arrived shortly to review and sign reports. At 8:45am the LPA conducted a tour of the physical plant with Staff Emma to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of five (5) resident bedrooms and three (3) bathrooms. There is caregiver lounge located in the backyard. The LPA observed (2) fully charged fire extinguishers last serviced on September 15,2023. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings throughout the facility. The facility serves residents with dementia, however there were no auditory alarms on the exit doors during today’s visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer. At 8:50 a.m. the LPA observed the kitchen sink in the process of being remodeled, however the home has a temporary makeshift sink that is operable. The LPA observed a bottle of Windex and a bottle of Palmolive liquid dish soap in the unlocked cabinet under the sink accessible to the residents in care. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BUTTERFLY INN, LLC, THE	FACILITY NUMBER: 567609911
	VISIT DATE: 10/06/2023

NARRATIVE

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Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 74 degrees.

Garage/laundry room: The garage is locked and used as a storage. The laundry equipment and cleaning supplies are kept in a locked outside laundry room.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. At 9:45 a.m. the LPA observed the following hazardous items in the backyard accessible to residents in care: two (2) hand-saws, multiple pliers, gardening tools, and paint. At 9:55 a.m. the LPA observed a pre workout container and vitamin container inside the caregiver lounge located in the backyard unlocked and accessible to residents in care.

Interviews: At 10:10 a.m. the LPA conducted two (2) resident and two (2) staff Interviews. No immediate concerns were voiced during todays visit.

Due to time constraints the LPA will return to complete annual at a later date.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/06/2023 12:00 PM - It Cannot Be Edited

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: BUTTERFLY INN, LLC, THE	FACILITY NUMBER: 567609911
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as the LPA observed cleaning supplies, gardening tools, handsaws, paint, and pre-workout which poses an immediate health and safety risks to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Plan of Correction has been met, as staff locked all hazardous items upon observation.

Type A

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as all exiting doors did not have auditory devices, including main entrance and resident exiting doors to the ouside which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Licensee will ensure all exit doors have auditory alarms and send proof to CCL by POC due date 10/7/23.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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