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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600798
Report Date: 07/21/2022
Date Signed: 07/21/2022 12:19:25 PM

Document Has Been Signed on 07/21/2022 12:19 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 IFACILITY NUMBER:
374600798
ADMINISTRATOR:ABILLE, RUDYARDFACILITY TYPE:
735
ADDRESS:1398-B 4TH AVENUETELEPHONE:
(619) 422-1181
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Rudyard AbilleTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Hamilton visited the facility to conduct an annual required licensing inspection which focused on infection control. LPA introduced herself and was granted entry into the facility by Administrator, Rudyard Abille. LPA disclosed the purpose of the visit.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness; face coverings worn by staff; hand sanitizer/hand washing stations readily available; available visitation area; and an ample supply of cleaning products and PPE.

LPA observed a table saw that contained a sharp blade accessible to clients in care. Deficiency was observed during today’s visit and is cited on the attached LIC 809D.

An exit interview was conducted with Rudyard Abille, and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) was provided at the facility.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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Document Has Been Signed on 07/21/2022 12:19 PM - It Cannot Be Edited


Created By: Elizabeth Hamilton On 07/21/2022 at 12:05 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 I
FACILITY NUMBER: 374600798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not ensure items that could pose a danger were inaccessible to 6 out of 6 clients. This posed an immediate safety risk to clients in care.
POC Due Date: 07/22/2022
Plan of Correction
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Administrator immediately stored the table saw making it inaccessible to clients. In addition the Administrator agreed to attend vendor training along with all staff regarding buildings and grounds. Administrator will submit proof of training by 08/05/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Denise Powell
LICENSING EVALUATOR NAME:Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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