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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603661
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:44:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2021 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20210729125519
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:
01/20/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Licensee, Leo EspinosaTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Staff did not treat resident(s) with dignity.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility to deliver findings for the above allegation. LPA was greeted at the front entrance by Caregiver, Samanta Galila, and granted entry after identifying herself. LPA explained the purpose of the visit and the elements of the complaint with the Licensee, Leo Espinosa.

The Department’s investigation included records review, and interviews with residents, staff and outside sources.

On July 29, 2021, it was alleged that staff did not treat a resident with dignity. It was specifically alleged that on July 27, 2021, staff 1 (S1 – See LIC 811 Confidential Names List) yelled at resident 1 (R1) while assisting them with bathing.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20210729125519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BUTTERFLY GARDENS II
FACILITY NUMBER: 374603661
VISIT DATE: 01/20/2023
NARRATIVE
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Interviews with outside sources revealed R1 did not like going into the bathroom and would get agitated when doing so. Interviews further revealed that during the date in question, R1 was agitated and did not want to shower; however, S1 involuntarily made R1 take a shower. S1 then spoke to R1 in a loud and disrespectful manner. Records reviewed confirmed R1 had a diagnosis of dementia and was notated to have severe agitation and combativeness with showers. Records obtained from an outside source and direct witness statements corroborated the incident in the shower and supported the allegation.

This Department investigated the allegation that the facility staff did not treat resident(s) with dignity. Based on interviews and records reviewed, the preponderance of the evidence standard has been met; therefore, the allegation has been deemed substantiated. A citation is being issued in accordance with California Code of regulations, Title 22, Chapter 1, Division 6 and listed on the LIC9099D and a plan of correction was developed with the Licensee.

An exit interview was conducted and a copy of this report, List of Confidential Names, LIC9099D, and Licensee/Appeal Rights (9058 01/16) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210729125519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BUTTERFLY GARDENS II
FACILITY NUMBER: 374603661
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
Section Cited
CCR
87468.1
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87468.1(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff…This requirement was not met as evidenced by:
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Licensee stated they will hold an outside source training on personal rights and dementia care regarding combativeness. They will submit verification of the staff sign in sheet along with training material to the department by February 20, 2023.
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Based on interviews and record reviews S1 did not treat R1 with dignity. This posed a potential personal rights risk to one out of six residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3