The Butterfly Inn

Type of visit: Required - 1 Year

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 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) 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.the state’s words, verbatim · CDSS document, Oct 15, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not meet residents’ oxygen needs.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial complaint visit was conducted on 02/13/2025 by LPA Esther Cortez. On today's visit, LPA Arroyo met with staff, Miguel Lopez as the Administrator was unable to come to the facility, however gave staff permissionto sign report. Entrance interview. During the initial visit on 02/13/2025, LPA Cortez conducted a plant tour, conducted interviews with the Administrator, three staff and one resident, and obtained copies of pertinent documents between 3:45 p.m. and 4:45 p.m. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not meet resident’s oxygen needs. It was reported that Resident #1 (R1) was observed with low oxygen levels, and R1’s oxygen machine was used to restore their oxygen levels to normal. However, facility staff were instructed to turn off the oxygen machine to conserve electricity. Records reviewed and interviews conducted revealed that R1 was admitted to hospice care on 05/20/2023, with a primary diagnosis of Alzheimer’s disease and secondary diagnoses of hypertension and depression. According to the hospice care plan dated 05/20/2023, the doctor’s orders included the use of a nebulizer and oxygen concentrator at 5L as needed for shortness of breath or wheezing. Interviews further revealed that R1’s oxygen and pulse levels are frequently monitored throughout the day. If the oximeter indicates that R1’s oxygen levels fall below 90%, staff are instructed to turn on R1’s oxygen machine. However, if the oximeter reads 100%, the oxygen machine is turned off to maintain R1’s safety. Additionally, all four staff members interviewed denied turning off R1’s oxygen when needed or advising another staff member to turn off the oxygen while in use. Furthermore, during an interview with a resident, resident denied being refused assistance or medications by facility staff, stating they had no concerns and were receiving great care. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “staff did not meet resident’s oxygen needs”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 29-AS-20250207100126

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the facility. LPA met with Alexander Tecson, Administrator and Amalia Davis, Assistant Administrator. LPA explained the purpose of the visit. The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there are five (5) residents residing in the facility. The facility has a fire clearance for six (6) non-ambulatory residents, of which six (6) can be bedridden, a hospice waiver for six (6) residents, and a dementia waiver for six residents. Entrance Interview Conducted: At the time of arrival, there four residents and four care staff including John Davis, Co-Administrator/Direct Care Staff, and Amalia Davis, Assistant Administrator/Direct Care Staff present in the facility. One resident is temporarily out of the facility due to receiving a higher level of care. Administrator Tecson stated he is present in the facility seven days a week approximately four hours each day. The facility consists of a common area and office area, kitchen, and dining area. Leading off the living room are three private bedrooms (Bedrooms 1, 2, 3) and a bathroom off the hallway. Bedroom 2 has a private bathroom. There are two additional private bedrooms (Bedrooms 4 & 5) and a bathroom leading from another hallway off the common area. The bathrooms off the hallway are accessible to all residents in care. The private bathroom in Bedroom 2 is only accessed by the resident who resides in Bedroom 2. Each bedroom has exits to the backyard areas of the facility. The bathrooms have secure grab bars and no skid flooring. The kitchen consists of refrigerator, built-in oven, stove top, microwave, coffee maker, rice maker, blender, toaster, dishwasher, water filter and a pressure cooker. Sharps are kept in a locked drawer located near the kitchen sink. Medications and First Aid kit are kept in a locked cabinet near the dining area. Medications and sharps are kept inaccessible to residents in care. The First Aid kit is complete. Please continue to 809-C, Pg 2. The living room and dining area are furnished with adequate furnishings to sustain a capacity of six residents. The facility maintains a comfortable room temperature. Residents’ records, personnel documents and records of confidentiality are kept in a locked closet in the common area. The backyard consists of visitation areas including tables. chairs, umbrella, benches, concrete paved walkway with railing, potted plants, fruit trees, and other natural vegetation. A staff room, storage area and laundry room are located behind the main dwelling and are inaccessible to residents in care. Emergency food is kept in the locked storage area. Residents may participate at will in various activities based on their individual interests and preferences. Residents are offered music entertainment in the facility, backyard walks, backyard activities consisting of games, rock painting, crocheting, playing musical instruments, and other activities of the residents’ choice. Excursions outside the facility include scenic drives, personal care appointments, special family recognition activities, and holiday celebrations. There are seven smoke alarms and one carbon monoxide detector, and one hard wired pull alarm that alerts the local fire department. Residents' records are up-to-date. Personnel records and staff trainings are current and up-to-date. All staff have been properly associated to the facility. At approximately 2:00 pm, water temperatures were measured as follows: Kitchen sink faucet, 115.0 degrees Fahrenheit (F); Bathroom #1 at hallway, 114.3 degrees F; Bathroom #2 at hallway, 113.3 degrees F; and the private bathroom in Bedroom #2 measured at 115.1 degrees F. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety and personal accommodations. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on 8/6/2024. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Oct 15, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 08:15 a.m. When the LPA arrived, there was two staff and five clients present. The LPA was greeted by Staff Emma Carranza and informed them of the reason for the visit. Administrator Alexander Tecson was unable to be present during todays visit and authorized staff Amelia Davis who arrived shortly to review and sign reports. At 8:45am the LPA conducted a tour of the physical plant with Staff Emma 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. There is caregiver lounge located in the backyard. The LPA observed (2) fully charged fire extinguishers last serviced on September 15,2023. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings throughout the facility. The facility serves residents with dementia, however there were no auditory alarms on the exit doors during today’s visit. 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. At 8:50 a.m. the LPA observed the kitchen sink in the process of being remodeled, however the home has a temporary makeshift sink that is operable. The LPA observed a bottle of Windex and a bottle of Palmolive liquid dish soap in the unlocked cabinet under the sink accessible to the residents in care. Bedrooms: 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. Report will continue on LIC809-C. 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 of 74 degrees. 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. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. At 9:45 a.m. the LPA observed the following hazardous items in the backyard accessible to residents in care: two (2) hand-saws, multiple pliers, gardening tools, and paint. At 9:55 a.m. the LPA observed a pre workout container and vitamin container inside the caregiver lounge located in the backyard unlocked and accessible to residents in care. Interviews: At 10:10 a.m. the LPA conducted two (2) resident and two (2) staff Interviews. No immediate concerns were voiced during todays visit. Due to time constraints the LPA will return to complete annual at a later date. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 6, 2023