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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600397
Report Date: 07/30/2024
Date Signed: 07/30/2024 06:25:28 PM

Document Has Been Signed on 07/30/2024 06:25 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:LYN'S HOME CARE IIFACILITY NUMBER:
374600397
ADMINISTRATOR/
DIRECTOR:
LYDIA S. ABILLEFACILITY TYPE:
735
ADDRESS:1365 EL LUGAR STREETTELEPHONE:
(619) 427-1830
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver Victoria Azucena, Licensee Lydia Abille, and House Manager Pia AbilleTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Victoria Azucena. LPA also met with Licensee Lydia Abille and House Manager Pia Abille, who arrived later during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of whom all must be ambulatory. Staff interviews and LPA observation showed there were a total of four (4) clients in care on today’s date. Review of each client’s respective LIC602 Physician’s Report showed that three (3) of the clients were indeed ambulatory, but the physician for Client #1 (C1) determined that C1 was non-ambulatory status. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] The facility’s operating license and prior-approved fire clearance did not authorize Licensee to care for non-ambulatory clients. The facility’s license does not include endorsements for secured perimeter or delayed egress doors, and neither were present during today’s visit.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected each room. Doors, windows, toilets, and shower were working. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings and extra linens were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 73 F. Hot water temperature at taps accessible to clients were also complaint: Kitchen Sink was 113.4 F and Bathroom Sink was 108 F. Appliances to preserve perishable food were compliant in temperature: Kitchen Refrigerator was 39 F and Kitchen Freezer was 0 F. Garage Freezer was 0 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

[CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
Document Has Been Signed on 08/14/2024 12:27 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/14/2024 12:22 PM


Created By: Dang Nguyen On 07/30/2024 at 02:53 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LYN'S HOME CARE II

FACILITY NUMBER: 374600397

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records review, for 1 of 4 clients (C1), Licensee operated the facility beyond the ambulatory status conditions/limitations specified on the license. This posed an immediate safey risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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2
3
4
During today's visit, C1 was not present. Staff interviews widely showed that C1 was able to walk with good balance and without assistive device. C1's only LIC602 Physician's Report (dated 08-28-2023) showed they were "occasionally confused" but also "able to follow instructions" and "able to communicate." During today's visit, Licensee contacted C1's physician to request an updated LIC602 to be completed; this resolves the immediate risk. As soon as a new LIC602 is received, Licensee agreed send a copy of it to LPA. If the physician insists that C1's status remains non-ambulatory, Licensee agreed that C1 must be served with an eviction notice.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 07/30/2024 06:25 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/30/2024 at 02:53 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LYN'S HOME CARE II

FACILITY NUMBER: 374600397

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, Licensee did not ensure that all staff were trained annually in the proper use of all required PPE. This posed a potential health risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agreed to have all current facility staff and managers trained on the proper use of PPE (to include specifically surgical masks, N-95 respirators, face shields/eye protection, gowns, gloves, and hand sanitizer). Licensee agreed to send a copy of the training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that the facility was clean at all times for the well-being of clients, employees and visitors. This posed a potential health and personal rights risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 08/30/2024
Plan of Correction
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3
4
During today's visit, Licensee contacted their local waste management utility company to schedule a pick up of the yard debris on 08-01-2024. Licensee agreed to hire a third-party professional housekeeper/cleaner to perform one deep clean of the facility, to include all bedrooms and common areas and bathrooms. Licensee agreed to send a copy of the paid receipt/invoice to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/30/2024 06:25 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/30/2024 at 02:53 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LYN'S HOME CARE II

FACILITY NUMBER: 374600397

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, in 1 of 3 bedrooms (Bedroom #3), Licensee did not ensure that the window screen was in good repair. This posed a potential health and personal rights risks to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agreed to replace the screen on the window in Bedrom #3, and to take a photo of it when completed. Licensee agreed to send the photo to LPA, by the POC due date.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that all containers, including movable bins, used for storage of solid wastes, had tight-fitting covers. This posed a potential health risks to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agreed to purchase five (5) trash cans with lids to replace existing ones at the facility. Licensee agreed to send a copy of the purchase receipt (or alternatively photos of the lidded trash cans in place) to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/30/2024 06:25 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/30/2024 at 02:53 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LYN'S HOME CARE II

FACILITY NUMBER: 374600397

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, for 1 of 5 staff sampled (S1), Licensee did not ensure that their personnel record contained the required health screening. This posed a potential health risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agreed to coordinate with S1 and their physician to obtain a completed and signed LIC503 Health Screening (or equivalent physical exam document) which evidences that S1 is both negative for tuberculosis and capable of performing their job duties at the facility. Licensee agreed to send this document to LPA, by the POC due date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on records review and staff interviews, for 1 of 5 staff sampled (S1), Licensee did not ensure that their personnel record contained the required tuberculosis test result. This posed a potential health risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 08/30/2024
Plan of Correction
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3
4
Licensee agreed to coordinate with S1 and their physician to obtain a completed and signed LIC503 Health Screening (or equivalent physical exam document) which evidences that S1 is both negative for tuberculosis and capable of performing their job duties at the facility. Licensee agreed to send this document to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/30/2024 06:25 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/30/2024 at 02:53 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LYN'S HOME CARE II

FACILITY NUMBER: 374600397

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)1
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. 1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on records review and staff interviews, 1 of 4 clients (C1) used an inhaler device, but Licenseed did not ensure that 5 of 5 direct care staff (S1, S2, S3, S6, and S7) were trained on use of inhaler devices by a licensed professional.
POC Due Date: 08/30/2024
Plan of Correction
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3
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Licnesee agreed to coordinate with a currently licensed professional (such as a licensed nurse) to train the facility's direct care staff on the correct/safe use of inhaler devices. The professional shall outline in writing the procedures staff should follow. Licensee agreed to send proof of trianing completion to LPA, by the POC due date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review and manager interview, Licensee did not conduct a disaster drill at least quarterly for each shift. This posed a potential safety risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 08/30/2024
Plan of Correction
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2
3
4
Per records seen today, Licensee recently performed a disaster drill on the afternoon (PM) shift. Licensee agreed to perform and document in writing two (2) more emergency/disaster drills: one will occur on the AM shift (6:00 AM to 2:00 PM), and one will occur on the NOC shift (10:00 PM to 6:00 AM). Licensee agreed to send proof of these drills to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/30/2024 06:25 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/30/2024 at 04:21 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LYN'S HOME CARE II

FACILITY NUMBER: 374600397

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
80019 Criminal Record Clearance: "(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: ...(3) Request a transfer of a criminal record clearance as specified in Section 80019(f)..."

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not ensure that 1 of 1 adults (P1) and 2 of 10 staff (S3 and S5), who were subject to a criminal record review, had, prior to working or residing in a licensed facility, requested and been approved for a transfer of a criminal record clearance. This posed a potential safety risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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2
3
4
For P1, S3, and S5 each: Licensee agreed to submit an LIC9182 Criminal Background Clearance Transfer Request form, along with a copy of that person's LIC508 Criminal Record Statement and a copy of their current official ID card, to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov), by the POC due date. Licensee agreed to Cc: LPA on the E-mail, when submitting these documents.
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records: "(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee." This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interviews: Licensee did not ensure that personnel records were maintained at the facility for 4 of 10 employees (S2, S3, S4, and S5). This posed a potential safety risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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2
3
4
For S2, S3, S4, and S5 each, Licensee agreed to collect the following signed and dated documents: LIC501 Personnel Record, LIC508 Criminal Record Statement, LIC503 Health Screening w/ negative tuberculosis test result indicated, and proof of current First Aid Training. Licensee agreed to keep copies of these records in employee files to be maintain on-site at the facility at all times. Licensee agreed to send copies of these same records for S2 through S5 to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LYN'S HOME CARE II
FACILITY NUMBER: 374600397
VISIT DATE: 07/30/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility’s swimming pool was locked/secured behind a fence and gate meeting regulatory requirements. There were no hazardous objects, active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility.

However, the facility was not in a state of general cleanliness. (For example, cobwebs were seen inside a kitchen cabinet. Kitchen cabinets had a film of grease on the outside. The shower and toilet shared by clients showed debris and/or visible staining. Interior floors showed dirt. There was unused debris/refuse in the facility’s backyard and near the front driveway). Also, the window screen in Bedroom #3 was worn and needed to be replaced. Multiple trash cans/containers did not have tight-fitting lids, as was required.

LPA reviewed administrative records, staff files, and client files. LPA also interviewed multiple facility staff and clients. Client interviews did not raise any licensing concerns. During records review, LPA observed, and manager interview confirmed: For full-time Staff #1 (S1), Licensee did not have for them a current LIC503 Health Screening (or equivalent document) and negative tuberculosis test result, as was required. S1 corroborated that they did not yet undergo those steps, despite having worked at the facility since the preceding year. Licensee did not maintain personnel files for on-call caregivers Staff #2 (S2) and Staff #3 (S3), both of whom have worked at least once in the last quarter. Licensee also did not maintain personnel files for Staff #4 (S4) and Staff #5 (S5), who performed support tasks at the facility. Per review of CCLD’s database: S3 and S5 were not associated to the facility’s employee roster. There was also one non-client and non-staff adult living on the premises (P1) who was not associated to the facility’s roster, as required. (LPA’s research showed: S1 through S5, and P1, had each been fingerprinted and possessed current criminal record/background clearances with CCLD.)


[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LYN'S HOME CARE II
FACILITY NUMBER: 374600397
VISIT DATE: 07/30/2024
NARRATIVE
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3
4
5
6
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8
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[CONTINUED FROM LIC 809-C, 1 of 2]

Records review, confirmed by staff interviews, further showed: C1 used an inhaler device (related to one of their medications) and relied on facility staff for assistance with medications. However, Licensee did not ensure that 5 of 5 of its direct care staff [S1, S2, S3, Staff #6 (S6), and Staff #7 (S7)] received training on inhaler-use from a licensed professional, as was required. Licensee also did not ensure that facility staff received training on the use of Personal Protective Equipment (PPE) annually, as required. Within the last quarter, Licensee performed one disaster drill on the evening (PM) shift. However, Licensee did not perform an emergency/disaster drill on the morning ("AM"; 6:00AM to 2:00 PM) or overnight ("NOC"; 10:00 PM to 6:00 AM) shift, as required.

Ten (10) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. Since one of the deficiencies also constituted a violation of the facility’s prior-approved fire clearance, an Immediate Civil Penalty of $500 was also assessed (refer to the LIC421-IM page). LPA also issued Technical Assistance (TA) regarding reserve PPE supplies and reserve client toiletries (refer to the attached LIC9102-TA pages).

An exit interview was conducted with the Abilles, to whom a copy of this report, the LIC 809-D pages, the LIC421-IM page, the LIC9102-TA pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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