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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603661
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:07:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
08/26/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240826180224
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: 5DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caregiver Joselle RiveraTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility did not have a staff alert feature at the door
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Joselle Rivera.

It was alleged the facility did not have a staff alert feature at the door. On 08/26/2024, it was reported to the Department the facility did not have an auditory alert feature at the entrance door. During multiple visits to the facility, the LPA observed the facility had an auditory alert feature at the entrance door, and the device was emanating sound when the door was opened.

The LPA also observed several exit doors and sliding windows used to exit the facility had auditory devices, but these devices were not operating properly. Some of these devices did not produce an auditory sound when engaged or were turned off due to the devices not operating properly. Review of physician’s reports for residents at the facility confirmed they were all diagnosed with dementia and could be confused.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 5
Control Number 08-AS-20240826180224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BUTTERFLY GARDENS II
FACILITY NUMBER: 374603661
VISIT DATE: 10/30/2024
NARRATIVE
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Based on observations and review of records, the facility did not have auditory devices, or alert features to monitor exit doors. This deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Caregiver Joselle Rivera.

An exit interview was conducted with Rivera, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240826180224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BUTTERFLY GARDENS II
FACILITY NUMBER: 374603661
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87705(j)
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87705 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 was not met as evidenced by:
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Staff agreed to replace all auditory/ alert features monitoring exit doors that are not working properly, and notify the LPA by 11/04/2024.
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Based on observations and review of records, the Licensee did not ensure exit doors had auditory, or alert features to monitor exit doors of residents with dementia, which posed a potential health, safety and personal rights risk to five of five 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
08/26/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240826180224

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: 5DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caregiver Joselle RiveraTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff allowed memory care resident to sign forms
Facility does not have a perimeter fence
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Joselle Rivera.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources.

It was alleged staff allowed a memory care resident to sign forms. On 08/26/2024, it was reported to the Department the facility staff had allowed Resident # 1 (R1) sign legal documents when an external agency visited R1. An interview with staff revealed some external agencies did ask residents to sign a visit form to confirm services were provided, but these agencies would ask staff to sign when the resident was not capable. Contact with the external agency providing services to R1 revealed R1’s Durable Power Of Attorney had signed the initial treatment form. (See LIC 9099C for continuation of report.)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240826180224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BUTTERFLY GARDENS II
FACILITY NUMBER: 374603661
VISIT DATE: 10/30/2024
NARRATIVE
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The agency was not able to provide information of who had signed the subsequent visit forms. The LPA reviewed records for this agency obtained at the facility, and there was no clear indication that R1 had signed any legal documents from that agency.

It was alleged the facility did not have a perimeter fence. On 08/26/2024, it was reported to the Department the facility did not have a perimeter fence. An observation by the LPA confirmed the facility did have a perimeter fence securing the facility's patio area. Although this fence did not extend to the front of the facility, the facility did have an auditory signal/ alert device at the main entrance door. Additionally, the facility did not have an approved locked perimeter fire clearance.

Based on the evidence obtained, the allegations were unsubstantiated.

An exit interview was conducted with Caregiver Rivera, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5