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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600397
Report Date: 07/17/2025
Date Signed: 07/17/2025 04:13:34 PM

Document Has Been Signed on 07/17/2025 04:13 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
SAN DIEGO RO, 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: 3DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Supervisor Pia AbilleTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Supervisor Pia Abille.

According to the facility’s license, the facility has a maximum capacity for six (6) clients, of whom all must be ambulatory. Per LPA observation, LIC602 Physician’s Reports, and staff interview: During today’s inspection, there were a total of three (3) clients in care, and all were ambulatory. LPA interviewed multiple staff and multiple clients who were present. LPA also reviewed the care records for all clients, and the personnel files for all active staff. LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility, inspecting all common areas and client bedrooms.

In the facility’s front yard, LPA observed two (2) old mattresses leaning against the shaded gazebo used by the clients. In the facility’s back yard, LPA observed assorted refuse, which staff confirmed was junk meant to be discarded (i.e. there was a metal bedframe leaning against the wall and sitting directly atop the facility’s gas main; there was a broken wooden dolly and other wood debris; there was a broken shopping cart).


[CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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
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)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LYN'S HOME CARE II
FACILITY NUMBER: 374600397
VISIT DATE: 07/17/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

In the facility Kitchen, the fume hood vent motor over the stove/range was non-working. In Client Bedroom #1, LPA observed the window screen had a 1-inch by 6-inch tear/hole in it along the bottom edge. LPA observed one (1) common housefly on the interior side of this same window screen; however, there were no other insects observed in the remainder of the facility. There was a three-dimensional layer of dust on the air vent and the windowsill of Bedroom #1; Licensee’s staff cleaned both during LPA’s visit. The facility’s floors showed evidence of dust and/or dirt; Licensee’s staff mopped all floors during LPA’s visit. Hot water temperature in the shared bathroom used by clients was initially too cold at 103.5 F. (Regulation requires hot water at such taps to be between 105 F and 120 F.) During today’s visit, adjustments were made to the facility’s water heater settings to bring the shared bathroom sink back into the compliant range.

The facility’s swimming pool is normally enclosed by a five-foot chain link fence with a padlocked gate. LPA observed the key to this padlock hanging on a cord near the gate, in plain view, thus defeating the lock. LPA was able to self-open the padlock and enter the pool area without staff becoming aware. The pool area gate was not of the self-closing type, as required. The pool area gate also did not have a self-latching device. (Regulation requires a self-latching device no more than six inches from the top of the gate). Part of the chain link of the fence was also bent/damaged, such that it left a hole large enough to be a foothold for someone trying to scale the fence.

Beyond the above, the facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were working. Extra linens, hygiene, and Personal Protective Equipment (PPE) supplies were present. The facility’s ambient internal temperature was complaint at 76 F. Refrigerator and freezer used to preserve perishable food were complaint in temperature. There were at least (2) days of perishable food and at least seven (7) days of non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good condition.


[CONTINUED FROM LIC 809-C, 2 of 2]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LYN'S HOME CARE II
FACILITY NUMBER: 374600397
VISIT DATE: 07/17/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

The facility did not have a fireplace. There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. Carbon monoxide detector, smoke detectors, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguisher was serviced within the last twelve (12) months. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. There was a locked area for central storage of medication. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility.

During LPA’s inspection of centrally-stored medications, LPA observed, and staff interview confirmed: For 3 of 3 clients, staff had transferred their medications from their original pharmacy packaging to unlabeled pill-organizer containers, for several days in advance. Manager interview confirmed that this went against Licensee’s training/instruction to staff.

Records review and manager interview showed: Within the last two (2) years, the facility’s administrator on record did not complete at least three (3) hours of training on Human Immunodeficiency Virus (HIV) and at least one (1) hour of training on Tuberculosis (TB), as required biennially by regulation.

Seven (7) deficiencies were cited per California Code of Regulations, Title 22. Since one of these deficiencies relates to accessible bodies of water, an immediate Zero Tolerance civil penalty of $500 was assessed/charged to Licensee. Since two (2) of the deficiencies were repeat violations within a twelve (12) month period, Repeat Civil Penalties totaling $500 were additionally assessed/charged to Licensee (refer to the LIC421-FC pages). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Supervisor Pia Abille, to whom a copy of this report, the LIC 809-D pages, the LIC421-IM page, the LIC 421-FC pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit. An electronic set of these same documents was E-mailed to the Licensee.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/17/2025 04:13 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/17/2025 at 02:55 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: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(e)
Building and Grounds
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on LPA observation and records review, Licensee did not ensure the inaccessibility of a swimming pool from 3 of 3 clients (Client #1, Client #2, and Client #3) with mental disorders. This posed an immediate safety risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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2
3
4
During today's visit, LPA handed the pool gate key to a facility manager and instructed them to keep it in a secure location not accessible or visible to clients, which they agreed to do. This action resolves the deficiency.
Section Cited
Deficient Practice Statement
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3
4
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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/17/2025 04:13 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/17/2025 at 02:55 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: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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3
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Based on LPA observation and manager interview, Licensee did not ensure that the facility was clean and in good repair at all times for the well-being of clients, employees and visitors. This posed a potential health and personal rights risk to 3 of 3 clients (Client #1, Client #2, and Client #3) in care.
POC Due Date: 08/17/2025
Plan of Correction
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During today's visit, facility staff removed dust from stated areas and mopped all floors, to LPA's satisfaction. Licensee agreed to either replace or repair the facility's kitchen fume hood vent motor, and to E-mail either purchase receipt or service invoice to LPA, by the POC due date. Licensee agreed to get rid of the two mattresses in the front yard and the described debris in the backyard, and to send photographs to LPA proving completion, by the POC due date.
Type B
Section Cited
CCR
80075(k)(5)
80075 Health Related Services: “(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records and interviews, Licensee did not ensure that centrally stored medications for 3 of 3 clients (Client #1, Client #2, and Client #3) were stored in their originally received container. This posed a potential health risk to persons in care.
POC Due Date: 08/17/2025
Plan of Correction
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Licensee agreed to immediately cease the practice of “pre-pouring” medications, instead only dispensing said pills/tablets from their original labeled pharmacy blister packs/bottles at the time that the client is ready to ingest them. Licensee agreed to retrain all staff on this change in procedure, and to E-mail the training sign-in sheet 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/17/2025 04:13 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/17/2025 at 02:55 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: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(e)(1)
Building and Grounds
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence. (1) Fences shall be at least five-feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and records review, Licensee did not ensure that the fence surrounding the pool was self-closing, and that it also had a self-latching device. This posed a potential safety risk to 3 of 3 clients in care (Client #1, Client #2, and Client #3) who have mental disorders.
POC Due Date: 08/17/2025
Plan of Correction
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Licensee agreed to coordinate with a licensed contractor to secure a quote/proposal to replace/repair the existing chain-link of the pool fence, to upgrade the pool gate to have both self-closing and self-latching mechanisms (the gate shall swing away from the pool when opened), and to ensure the entire fence and gate meet current Uniform Building Codes. Licensee agreed to E-mail the quote/proposal to LPA and to commence project work with the vendor, 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/17/2025 04:13 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/17/2025 at 02:55 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: 07/17/2025

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
1
2
3
4
Based on LPA observation, Licensee did not ensure that a window screen in 1 of 3 bedrooms was in good repair. This posed a potential health and personal rights risk to 3 of 3 clients (Client #1, Client #2, and Client #3) in care.
POC Due Date: 08/17/2025
Plan of Correction
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2
3
4
Licensee agreed to repair/replace the window screen in Bedroom #1, and to E-mail a photo of such to LPA, by the POC due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA instrument measurement, Licensee did not maintain water temperature controls to automatically regulate the hot water delivered to plumbing fixtures used by clients to be not less than 105 F and not more than 120 F in temperature. This posed a potential safetly and personal rights risk to 3 of 3 clients (Client #1, Client #2, and Client #3) in care.
POC Due Date: 07/17/2025
Plan of Correction
1
2
3
4
During today's site visit, adjustments were made to the settings on the facility's water heater, which brought all hot water taps accessible to clients back into the complaint temperature range. This action resolved the deficiency.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/17/2025 04:13 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/17/2025 at 02:55 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: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and manager interview, Licensee did not ensure the facility administrator on record had received training on HIV and TB within the last two years, as required. This posed a potential health and personal rights risk to 3 of 3 clients (Client #1, Client #2, and Client #3) in care.
POC Due Date: 08/17/2025
Plan of Correction
1
2
3
4
Licensee agreed to have the facility administrator complete three (3) hours of retraining on HIV and one (1) hour of retraining on TB, and to E-mail proof of training completion to LPA, by the POC due date. Going forward, Licensee agreed to ensure the administrator completes said training at least biennially, and to maintain ready proof of such on an ongoing basis.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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