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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600798
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:34:07 PM

Document Has Been Signed on 07/23/2024 04:34 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/
DIRECTOR:		ABILLE, RUDYARDFACILITY TYPE:
735
ADDRESS:1398-B 4TH AVENUETELEPHONE:
(619) 422-1181
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Licensee Lydia AbilleTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 07-19-2024. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Lydia Abille.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of whom all must be ambulatory. Per review of LIC602 Physician’s Reports, staff interviews, and LPA observation: During this inspection, there were a total of six (6) clients in care, and all were ambulatory. 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. The facility was reasonably clean/sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilet, and shower were working. Extra linens and hygiene supplies 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 74 F. Hot water temperature at a tap accessible to clients was initially non-compliant: Bathroom #1 Sink was 138.7 F, when regulation specified that the maximum allowed was 120 F. [During LPA’s visit, adjustments were made to the facility’s water heater, such that hot water temperature at Bathroom #1 Sink was brought down to 107.1 F.] Appliances to preserve perishable food were compliant in temperature: Kitchen Refrigerator was 39 F and Kitchen 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]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 5
Document Has Been Signed on 07/23/2024 04:34 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/23/2024 at 02:48 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: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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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 an immediate safety risks to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 07/23/2024
Plan of Correction
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During LPA’s visit, adjustments were made to the facility’s water heater, such that hot water temperature at all taps used by clients were brought within the required temperature range. This action resolved the deficiency.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/23/2024 04:34 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/23/2024 at 02:48 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: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.4(c)
Observation of the Client
(c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: The Licensee did not ensure that 6 of 6 clients (C1 through C6) were regularly observed for changes in physical functioning, specifically weight gain/loss. This posed a potential health risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee agreed to measure and log the body weights of C1 through C6, and to E-mail copies of these logs to LPA, by the POC due date. Going forward, Licensee agreed to weigh each resident in care once per month, and to record/log the weight in writing in the client's care file.
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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Based on records review and manager interview: Licensee did not conduct an emergency/disaster drill at least quarterly for each shift. This posed a potential safety risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee agreed to perform a total of three (3) emergency/disaster drills and to documetn the results of the drills in writing. One drill will occur on the AM shift (6:00 AM to 2:00 PM), one will occur on the PM shift (2:00 PM to 10:00 PM), and one will occur on the overnight NOC shift (10:00 PM to 6:00 AM). Licensee agreed to E-mail proof of drill completion, by the POC due date. Going forward, Licensee agrees to drill each shift at least once per quarter and to maintain written proof of such.
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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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 I
FACILITY NUMBER: 374600798
VISIT DATE: 07/23/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

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. No pools or bodies of water were observed on the premises. 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.

LPA reviewed administrative records and the files for multiple staff and all current clients. LPA also interviewed multiple facility staff and clients. During this process, LPA observed, and manager interview confirmed: Licensee did not maintain a personnel file for active employee Staff #1 (S1), as was required. However, review of CCLD records showed that S1 did possess a current background clearance, and Licensee showed proof that S1 had current First Aid Training. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Licensee did not maintain a record of body weight for Client #1 (C1) through Client #6 (C6). Regulation required Licensee to “regularly observe” clients for changes in physical condition, to include “unusual weight gains or losses.” Licensee also did not perform an emergency/disaster drill on each work shift at least once per quarter, as was required.

Three (3) 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. LPA also issued three (3) Technical Violations (TV’s) regarding proof of First Aid Training for on-call Staff #2 (S2), regarding associating S1 and S2 to the facility's staff roster, and regarding documentation of medication training for direct care staff (see the LIC9102-TV pages).

An exit interview was conducted with Abille. A copy of this report, the LIC 809-D pages, the LIC9102-TV pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/23/2024 04:34 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/23/2024 at 03:29 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: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: Licensee did not maintain at the facility a personnel record/file for 1 of 6 staff (S1). This posed a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee agreed to obtain for S1 the following completed and signed documents: LIC501 Personnel Record, LIC508 Criminal Record Statement, and LIC503 Health Screening with negative tuberculosis test result. Licensee agreed to deliver these documents to LPA, by the POC due date.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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