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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604536
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:31:03 PM

Document Has Been Signed on 04/12/2022 03:31 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 GARDENSFACILITY NUMBER:
374604536
ADMINISTRATOR:ESPINOSA, LEOFACILITY TYPE:
740
ADDRESS:5332 MOUNT BURNHAM DRIVETELEPHONE:
(858) 666-1075
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: 6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alex JoTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an announced Pre-Licensing visit on 4/12/2022. LPA was met by Applicant Alex Jo and was granted entry into the facility. The purpose of today's visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on February 24, 2022 and the facility is approved for 5 non-ambulatory residents and 1 bedridden resident.

During today's visit, LPA toured the facility and inspected every room. The facility was found to be clean and in good repair with no pathway obstructions. Resident bathrooms were observed to be clean and the toilets and showers were found to be in working order. The facility's water temperature in bathroom 1 was measured at 110.5 degrees Fahrenheit and bathroom 2 was measured at 110.5 degrees Fahrenheit. LPA observed locked storage areas where all hazardous and/or toxic chemicals were stored and secured. LPA observed locked storage for residents' medications. A fire extinguisher was observed throughout the facility and found to be in compliance. A functioning carbon monoxide detector and smoke detectors were observed in the facility. No bodies of water were observed near or on the premises. LPA observed 7-day supply of non-perishable food and a 2-day supply of perishable food. Required postings were observed in a common area of the facility.

LPA conducted Component III with the applicant. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance.

Pre-licensing is complete, and this facility has no deficiencies. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted with Applicant Alex Jo and a copy of this report was provided via email.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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