374600798-7-10-2025-08-AS-DNGN-DJFTP3-20250710145339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600798
Report Date: 07/10/2025
Date Signed: 07/10/2025 02:54:02 PM

Document Has Been Signed on 07/10/2025 02:54 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 I		FACILITY NUMBER:	374600798
ADMINISTRATOR/ DIRECTOR:	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:	07/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Caregiver Jovita Caniya and Supervisor Pia Abille		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 Caregiver Jovita Caniya. LPA then met with Supervisor 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. Per LPA observation, LIC602 Physician’s Reports, and staff interview: During today’s inspection, there were a total of six (6) 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 multiple staff. During the facility tour, LPA observed: The facility did not have a carbon monoxide detector, as required. When measured with thermometer, hot water temperature at taps accessible to clients were too hot: Kitchen Sink was 134.4 F, Bathroom #1 Sink was 138 F, and Bathroom #2 Sink was 133 F. (Regulation requires taps used by clients to be between 105 F and 120 F when turned to hot.) Bathroom #1 had no working lighting. Manager interview confirmed that this was not due to the missing ligh tbulb in the overhead fixture, but rather the overhead fixture not having working electricity, which Licensee has been aware of for at least a week but had not yet called in an electrician for. (Electricity in other parts of the facility was working.) LPA observed dust and cobwebs on some walls, surfaces, and floors of common areas; this topic also came up during a client interview. [CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

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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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)

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Document Has Been Signed on 07/10/2025 02:54 PM - It Cannot Be Edited

Created By: Dang Nguyen On 07/10/2025 at 01:45 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: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1503.2

General Provisions

Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and manager interview, Licensee did not have one or more carbon monoxide detectors in the facility. This posed an immediate safety risk to 6 of 6 clients (Client #1 through Client #6) in care.
	POC Due Date: 07/11/2025
	Plan of Correction
1 2 3 4	Licensee agreed to purchase and install two (2) carbon monoxide detectors (one for the first floor, and one for the second floor). Licensee agreed to E-mail to LPA the purchase receipt and photos of these devices plugged-in, by the POC due date.

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
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 an immediate safety risk to 6 of 6 clients (Client #1 through Client #6) in care.
	POC Due Date: 07/11/2025
	Plan of Correction
1 2 3 4	During today's site visit, LPA and facility staff made adjustments to the facility's water heater, but remained unsucessful in bringing taps back into the compliant temperature range. Licensee agreed contact a third-party licensed professional to investigate and address the issue. Licensee agreed to E-mail LPA the name of this professional/company and the appointment date and time, 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: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/10/2025 02:54 PM - It Cannot Be Edited

Created By: Dang Nguyen On 07/10/2025 at 01:45 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: 07/10/2025

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
1 2 3 4	Based on observation, Licensee did not ensure 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 6 of 6 clients (Client #1 through Client #6) in care.
	POC Due Date: 08/10/2025
	Plan of Correction
1 2 3 4	Licensee agreed to hire a licensed electrician to restore electricity to Bathroom #1. Licensee also agreed to hire a professional housekeeper to perform a one-time deep cleaning of the entire facility (i.e., all common areas, bathrooms, and bedrooms on both floors). License agreed to E-mail the paid electrician and housekeeping invoices to LPA, by the POC due date.

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 6 of 6 clients (Client #1 through Client #6) in care.
	POC Due Date: 08/10/2025
	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.

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: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LYN'S HOME CARE I	FACILITY NUMBER: 374600798
	VISIT DATE: 07/10/2025

NARRATIVE

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[CONTINUED FROM LIC 809] 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 and screens, 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.

The facility did not have a swimming pool (or similar body of water) or fireplace. There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. 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. Medications were stored in their original pharmacy packaging with prescription labels. 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.

Records review and manager interview showed: Within the last two (2) years, the facility’s administrator 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.

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 LIC809-D pages). Since two of these deficiencies are repeat violations within a twelve (12) month period, Repeat Civil Penalties totaling $500 were 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 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: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC809 (FAS) - (06/04)

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