<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603661
Report Date: 05/19/2022
Date Signed: 05/19/2022 04:33:23 PM

Document Has Been Signed on 05/19/2022 04:33 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BUTTERFLY GARDENS IIFACILITY NUMBER:
374603661
ADMINISTRATOR:LEO ESPINOSAFACILITY TYPE:
740
ADDRESS:5557 SOLEDAD MOUNTAIN ROADTELEPHONE:
(858) 764-4442
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 6CENSUS: 6DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Administrator, Leo Espinosa, and Caregivers, Samantha Galila and Joselle RiveraTIME COMPLETED:
04:40 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), Sabel Martinez, visited the facility to conduct an annual required licensing inspection. The LPA was met by Caregivers, Samantha Galila and Joselle Rivera, and was granted entry into the facility, after discussing the purpose of the visit, and identifying himself. The Administrator, Leo Espinosa, arrived during the visit.

During today's visit, the LPA toured the facility, and verified compliance with infection control practices. The LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply personal protective equipment.

During a tour of the exterior of the facility, Caregiver Samantha Galila, and the LPA observed one lock to a body of water/swimming pool gate to be unlocked. After further inspection, this lock was deemed to be out of order. This deficiency was cited in an LIC 9099D.

An exit interview was conducted with Administrator, Leo Espinosa, to whom a copy of this report, and Licensee Rights (LIC 9058 FAS 01/16) were provided to.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/19/2022 04:33 PM - It Cannot Be Edited


Created By: Sabel Martinez On 05/19/2022 at 03:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BUTTERFLY GARDENS II
FACILITY NUMBER: 374603661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited

1
2
3
4
5
6
7
87307 Personal Accommodations and Services (e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of...swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not mer as evidenced by:
8
9
10
11
12
13
14
Based on observation, and interviews, the licensee did not ensure the swimming pool to be secured which posed and immediate health, safety and personal rights risk to 6 of 6 residents in care
8
9
10
11
12
13
14
Adminstrator will train staff on the importance of secured bodies of water, and submit a log of attendees by 6/2/2022.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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:Denise Powell
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2