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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609911
Report Date: 10/15/2025
Date Signed: 10/15/2025 03:47:06 PM

Document Has Been Signed on 10/15/2025 03:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BUTTERFLY INN, LLC, THEFACILITY NUMBER:
567609911
ADMINISTRATOR/
DIRECTOR:		TECSON, ALEXANDER MFACILITY TYPE:
740
ADDRESS:4370 WHITTIER COURTTELEPHONE:
(805) 676-1909
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 5DATE:
10/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Amelia (Mae) DavisTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:25AM. When the LPA arrived, there were 2 (two) staff and 5 (five) residents present. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Alexander Tecson was unable to be present during today's visit and authorized facility designee Amelia (Mae) Davis to review and sign reports. Entrance interview conducted.

Beginning at 10:50AM, the LPA, along with facility designee conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of five (5) resident bedrooms and three (3) bathrooms. The LPA observed 2 (two) fully charged fire extinguishers last serviced on 09/15/2025. Hardwired combination smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings throughout the facility.

Bedrooms/Bathrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed full bed rails on all 5 (five) residents' beds. Record review revealed 2 (two) residents (Resident #1 - R1 and Resident #2 - R2) are receiving hospice services however, neither R1 nor R2's hospice care plans indicated the need for full bed rails. There are 3 (three) full bathrooms in the facility; 2 (two) are located in the hall and are designated for shared use, 1 (one) is designated for private resident use.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BUTTERFLY INN, LLC, THE
FACILITY NUMBER: 567609911
VISIT DATE: 10/15/2025
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 Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature throughout the visit. LPA noted that the front door contains a dead bolt that requires the use of a key to unlock/lock on the exterior and interior. The door was observed to be locked with a key. Facility Designee unlocked the dead bolt during the visit. Hall closets are locked and contain resident personal care/grooming items, and one closet contained resident medications.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects are stored in a locked drawer.

Garage/Laundry Room: The garage is locked and used as a storage. The laundry equipment and cleaning supplies are kept in a locked outside laundry room. Attached to the facility garage is a staff room, which was observed to be locked.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. The backyard contains a water fountain and a small birdbath. LPA advised facility designee to ensure residents' medical assessments are updated to reflect the regulation changes effective 01/01/2025 which address resident risk with access to smaller water features.

File Review: Beginning at 11:10AM, LPA reviewed 4 (four) staff and 5 (five) resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All 4 (four) of 4 (four) staff files reviewed were complete and contained all documents. All 5 (five) of 5 (five) residents have full bed rails on their beds, but are either not on hospice or do not have hospice care plans which indicate the need for full bed rails.

Medication Audit: Medications were reviewed beginning at 12:30PM. Medications are centrally stored and locked in a cabinet in the hallway. Medications for 2 (two) residents were observed. Medications observed appeared to be administered and documented in compliance with regulation.

Emergency Disaster Plan/Infection Control: The LPA reviewed the facility's Infection Control Plan, Disaster

Report Continued on LiC 809-C (p.3)

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BUTTERFLY INN, LLC, THE
FACILITY NUMBER: 567609911
VISIT DATE: 10/15/2025
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Plan and evacuation drills. Both Emergency Disaster plan and Infection control plan appeared to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last evacuation drill documented on 09/29/2025.

Interviews: LPA conducted interviews with 1 (one) resident and 2 (two) staff. No immediate concerns were voiced during the visit.

Documents Obtained: LPA received a copy of the facility's liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalty issued in the amount of $500.

Exit interview conducted and copy of the report and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2025 03:47 PM - It Cannot Be Edited


Created By: Kelly Dulek On 10/15/2025 at 02:14 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BUTTERFLY INN, LLC, THE
FACILITY NUMBER: 567609911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the front door was observed to have a double cylinder deadbolt (one that requires a key to unlock on both the interior and exterior sides of the door) which was locked during the visit which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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During today's visit, Facility Designee unlocked the deadbolt and ensured the lock remained unlocked during the visit. Designee understands this lock cannot be used on any emergency exit. Licensee will remove the lock and submit proof to CCL by 10/24/2025.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 4 residents have full bed rails on their beds and 3 residents are not on hospice and 1 hospice resident has orders for half bed rails but has full bed rails on their bed, which poses an immediate personal rights risk to persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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During today's visit, facility designee contacted the hospice agencies for the resident on hospice to obtain orders/plan of care specifying residents' need for full bedrails. Facility Designee understands residents not on hospice care cannot have full bed rails. Designee will discuss with Licensee resident needs and submit a written plan to CCL by POC due date indicating whether full bed rails will be replaced with half rails (with orders) or if the facility will request exceptions.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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