198320479-10-9-2024-11-AS-PBUR-D9VPPT-20241009113003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320479
Report Date: 10/08/2024
Date Signed: 10/09/2024 11:30:55 AM

Document Has Been Signed on 10/09/2024 11:30 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BUTTERFLY LOVE RESIDENTIAL CARE HOME LLC		FACILITY NUMBER:	198320479
ADMINISTRATOR/ DIRECTOR:	CRAIG, GWENDOLYN		FACILITY TYPE:	740
ADDRESS:	153 WEST ARBOR VITAE STREET		TELEPHONE:	(424) 356-8595
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90301
CAPACITY: 6		CENSUS: 0	DATE:	10/08/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Gwendolyn "Gwen" Craig		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 Analyst (LPA) Pamela Bunker made an announced visit and met with Applicant Gwendolyn "Gwen" Craig to conduct a Pre-Licensing evaluation. An application was submitted to the Department of Social Service; Community Care Licensing Division (CCLD) on April 02, 2024, for an initial application for Adult Residential for ages 18-59 years. The requested capacity is for six (6) ambulatory. Structure: The facility is a two-story commercial residential facility located in a business residential neighborhood with four (4) bedrooms, two (2) full bathrooms, a receptionist area, a living/family room, a dining room, an office, kitchen, laundry room, and storage room. The facility features a shaded balcony patio and an indoor/outdoor activity area located at the rear of the building. A community parking structure is located on the left side of the property. Two (2) exits are located in the dining room, and the back exit door is near the laundry room. The front and backyard landscapes were in good condition. Residents Bedrooms: There shall be no more than two clients per one bedroom. Bedrooms #1 and #2 have two twin-size beds, a chest of drawers, a chair, a nightstand, a lamp, closets, and drawer space. Bedrooms #3 and #4 are equipped with one twin bed, two chests of dressers, two chairs, two nightstands, chest of drawers. Staff Bedroom: There will be no living staff. Bathrooms: The bathrooms have a working toilet, wash basin, and bathtub/shower. Linens & Hygiene Supplies: The required linen/supplies, including pillowcases, mattress paddings, sheets, fitted sheets, blankets, comforters, bedspreads, bath towels, hand towels, and washcloths, along with an adequate supply of linens, are stored in the hallway linen closets. Personal hygiene supplies for residents, including feminine napkins, soap, toothpaste, toothbrushes, toilet paper, hair brushes, and combs, are kept in the hallway cabinet. See continued LIC809-C page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BUTTERFLY LOVE RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 198320479
	VISIT DATE: 10/08/2024

NARRATIVE

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Continued LIC809-C page #2

Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in the hallway on the wall bulletin board. The facility has a landline telephone located in the office and receptionist area. Two (2) fully charged fire extinguishers are located in the kitchen and hallway. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected, and in good repair, knives, cutlery, and other sharp kitchen utensils will be stored locked in a drawer located in the kitchen. Smoke/Carbon Monoxide Detectors: There are hardwire battery backup smoke alarms and carbon monoxide detectors located in the living room, hallway, dining room, kitchen, bedrooms, and laundry room, which are operational. Appliances: Refrigerator, stove/oven, microwave, Keurig coffee maker, and washer/dryer are installed and all are in working condition. There is central air and heat throughout the facility. The hot water heater is outside located in the back of the house on the left side never the kitchen. Toxins: Cleaning supplies and toxins will be stored locked in a separate cabinet located in the laundry room only accessible to staff. Water Temperature: The hot water tested in the kitchen temperature was tested at 113 degrees Fahrenheit within the normal limits (105-120F degrees). Medication, First-Aid Kit & Manual: Centrally stored medications will be secured in a locked cabinet adjacent to the office, near the kitchen in the hallway. There are sufficient bandages, tweezers, thermometers, scissors, and first aid kits with manual. Staff & Clients Files: All staff and resident records will be kept confidential and securely stored in a locked cabinet within the office. The applicant will not be responsible for managing residents' cash resources. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on July 03, 2024. The facility yard is free of debris and hazards.

See continued LIC809-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BUTTERFLY LOVE RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 198320479
	VISIT DATE: 10/08/2024

NARRATIVE

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Continued LIC809-C page #3

Component III Orientation:

Component III was completed with the Applicant Gwendolyn "Gwen" Craig during the Pre-Licensing visit. Information was provided on how to operate the facility in substantial compliance with regulations. When asked about her understanding of Title 22 regulations, the applicant affirmed her comprehension.

LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. Should the applicant have any questions regarding the status of the application, she has been instructed to contact the CAU analyst assigned to her application.

An exit interview was conducted, and a copy of this report was provided to the applicant.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

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