374600798-12-18-2024-08-AS-SJAB-DC5V9Z-20241220151510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600798
Report Date: 12/18/2024
Date Signed: 12/18/2024 05:55:14 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2024 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20241213121158

FACILITY NAME:	LYN'S HOME CARE I		FACILITY NUMBER:	374600798
ADMINISTRATOR:	ABILLE, LYDIA		FACILITY TYPE:	735
ADDRESS:	1398-B 4TH AVENUE		TELEPHONE:	(619) 422-1181
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY:	6	CENSUS: 6	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Caregiver Rudyard “Rudy” Abille and Licensee Lydia Abile		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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-Licensee did not assist client with medication as prescribed.
-Licensee did not meet reporting requirements related to medication error.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Rudyard “Rudy” Abille. LPA also spoke with Licensee Lydia Abile via phone during today’s visit.

The Complainant alleged that during December 2024, Licensee did not give Client #1 (C1) medications as prescribed, and that Licensee also did not meet reporting requirements related to medication errors. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour, welfare check on C1, audit of medication inventory, and review of pertinent care and medication records. LPA also interviewed C1 and relevant facility staff and outside sources.

[CONTINUED ON LIC 9099-C, 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241213121158

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 I	FACILITY NUMBER: 374600798
	VISIT DATE: 12/18/2024

NARRATIVE

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[CONTINUED FROM LIC 9099]

According to C1’s Face Sheet and latest LIC625 Appraisal/Needs and Services Plan, they had a case management agency acting as their authorized representative for health matters. C1’s medication-prescribing physician (PCP) was also employed through C1’s case management agency. According to C1’s latest LIC602 Physician’s Report, C1’s doctor diagnosed them with Schizophrenia and Depression but also wrote that they were not confused, able to follow instructions, and able to communicate. However, C1’s doctor determined that C1 required staff assistance to safely store and take their medications.

Records and interviews, corroborated by LPA observation, aligned to show: On 12/04/2024, C1’s pharmacy delivered refills to the facility for most of C1’s prescribed medications, except for four (4) of them. Of these four (4), two (2) were not refilled because they had been discontinued by PCP. However, the other two (2) medications [i.e., “Medication A” and “Medication B”] still had active orders/prescriptions and said refills were needed by C1. Per C1’s official medication list, “Medication A” was to be taken once per day in the morning before noon, and “Medication B” was to be taken once per day at bedtime. C1’s pharmacy on 12/04/2024 provided written notice to Licensee’s staff that Medication A and Medication B were not refilled due to awaiting needed authorization from PCP. Then on 12/11/2024, C1 took their last doses of Medication A and Medication B. Licensee’s staff did not independently contact/alert either PCP or RP leading up to C1 running out of medication, or initially after C1 had run out of those medications.

During an unrelated visit on 12/12/2024, outside case management personnel recognized that C1 had run out of Medication A. They alerted PCP, who coordinated with C1’s pharmacy for the refill of Medication A to be delivered that same afternoon. Licensee’s staff resumed giving C1 their Medication A starting 12/13/2024 (the next morning after refill receipt). As a result of the above, C1 missed one (1) morning dose of their Medication A on 12/12/2024.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241213121158

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 I	FACILITY NUMBER: 374600798
	VISIT DATE: 12/18/2024

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

During an audit of C1’s medication inventory on 12/18/2024: LPA verified that Medication A was on-hand for C1 and had been given correctly since it was refilled. However, LPA identified that Licensee did not have any Medication B in stock for C1. Review of records and interviews of staff and outside sources showed that Medication B was still an active prescription for C1. Licensee’s staff last gave C1 their Medication B dose at bedtime on 12/11/2024, and they did not recognize that C1 was not receiving Medication B (from 12/12/2024 through 12/17/2024) until LPA’s involvement today. [During today’s visit, facility staff and LPA together made phone calls to C1’s PCP/case management agency and pharmacy to rectify the problem.]

Per interview of C1 on 12/18/2024: Although they were unfamiliar with the names of their prescribed medications, they told LPA they knew they had not been receiving their bedtime medication (i.e., Medication B) recently, which had caused them experience body shakes and to feel more “anxious” than usual. LPA observed that Medication B was designed to treat both depression and anxiety.

Based on LPA observation, records, and interviews, a preponderance of evidence exists to show that Licensee did not assist C1 with medication as prescribed, and that Licensee did not meet reporting requirements related to medication errors. Both allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Since one of the allegations contributed to exacerbation of illness for C1, an Immediate Civil Penalty of $500 was also charged/assessed to Licensee (refer to the LIC421-IM page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Rudyard Abille and Lydia Abille, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, 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: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241213121158

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 I	FACILITY NUMBER: 374600798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/18/2024 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	80075 Health Related Services: “(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	During today’s visit, LPA verified that C1 had Medication A in stock, and phone calls were made to PCP and pharmacy to refill their Medication B. Licensee will continue to track until Medication B arrives. These actions resolved the immediate risk.
	8 9 10 11 12 13 14	Based on observation, records, and interviews, Licensee did not ensure that 1 of 6 clients (C1) was assisted as needed with self-administration of prescription medications, which posed an immediate health risk to persons in care.	8 9 10 11 12 13 14
Type B 01/17/2025 Section Cited CCR 85075.4(c)	1 2 3 4 5 6 7	85075.4 Observation of the Client: “(c) The licensee shall bring observed changes…to the attention of the client's physician and authorized representative, if any.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit to CCLD an LIC624 Incident Report describing C1 not receiving Medication A on 12/12/2024, and not receiving Medication B from 12/12/2024 through 12/17/2024 (or when resumed). Licensee agreed to conduct an in-service training with the direct care staff of the facility, reminding them to: a) Call clients’ pharmacies to verify that refills will be delivered before supplies of those medications run out; b) If pharmacies indicate that a refill cannot be fulfilled due to a problem, to immediately call the clients physician and responsible person to troubleshoot; and, c) Immediately notify the clients’ physician and responsible person about any medication error, and seek out physician instruction on how to proceed in light of the error. Licensee agreed to send the training sign-in sheet to LPA, by the POC due date.
	8 9 10 11 12 13 14	Based on observation and interviews, for 1 of 6 clients (C1), Licensee did not bring observed change(s) to the attention of the client’s physician and authorized representative. This posed a potential health risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

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