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25 | Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Lydia "Lyn" Abille.
Today's visit was in response to Licensee verbally disclosing (during a separate annual inspection visit) that Client #1 (C1) and Client #2 (C2) previously left the facility on separate dates, and each has not yet returned to the facility. [See LIC 811 Confidential Names List for a description of select person identifiers used.] During today’s visit, LPA performed a brief facility tour / welfare check on remaining clients, finding no immediate safety concerns. LPA collected copies of and reviewed C1 and C2’s care and administrative records and interviewed staff. Records review and interviews showed:
C1, who was diagnosed with Bipolar 1 disorder and had a history of polysubstance use, moved into the facility during the early afternoon of 01/28/2025. Around twenty minutes later, C1 left on foot by themselves, telling Licensee they intended to go shopping. C1 briefly returned to the facility unharmed around 11:00 AM on 01/29/2025, then a few minutes later, departed the facility again on foot by themselves. C1 did not return to the facility this time. On 01/31/2025 around 9:00 AM, Licensee phoned the Chula Vista Police Department (CVPD) to file a missing person’s report on C1. CVPD quickly informed Licensee that C1 had recently checked themselves into a local behavioral health hospital and they were discharged from that location on 01/30/2025; their location was now unknown. Licensee then phoned C1’s assigned case manager to report them missing. There have been no updates on C1’s whereabouts or condition since. Licensee had assessed C1 prior to move-in and determined that they were not confused. Licensee was under the impression that C1 was able to safely leave the facility unassisted. However, per C1’s LIC602 Physician’s Report (dated 01/25/2025), while their doctor wrote that C1 was not confused, C1 was also deemed not able to safely leave the facility unassisted.
[CONTINUED ON LIC 809-C] |
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C2, who was diagnosed with Bipolar disorder, moved into the facility on 01/29/2025. Then on 03/15/2025 around 5:00 PM, C2 told staff that they intended to go “to the library” and left the facility on foot by themselves. C2 did not return to the facility. On 03/17/2025 around 9:00 AM, Licensee phoned CVPD to file a missing person’s report on C2. Licensee then phoned C2’s assigned case manager to report them missing. There have been no updates on C2’s whereabouts or condition since. Unlike C1, C2’s doctor on their LIC602 Physician’s Report had determined that C2 was able to safely leave the facility unassisted.
A review of records showed that while Licensee consistently called local law enforcement around two days after the clients’ departures, Licensee did not have missing client procedures codified in a written Absentee Notification Plan for C1 or C2, nor for Client #3 (C3) through Client #6 (C6), as was required. Prior to LPA’s site visit on 03/21/2025, Licensee also had not notified CCLD of either C1 or C2’s absences from the facility.
One (1) deficiency was cited per California Health and Safety Code, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee.
An exit interview was conducted with Licensee Abille, to whom a copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/21/2025
Section Cited
HSC
1507.15
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7 | 1507.15 Absentee notification plan for missing residents or participants: “Every community care facility that provides adult residential care… shall…develop and comply with an absentee notification plan for each resident... The plan shall be part of the written Needs and Services Plan [and] shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s…authorized representative when that resident…is missing from the facility and the circumstances…in which [they]…shall notify local law enforcement…” | 1
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7 | As of the date of deficiency issuance, Licensee had notified local law enforcement and applicable social workers that C1 and C2 are missing. Licensee agreed to author an Absentee Notification Plan meeting the requirements of HSC 1507.15, to place a copy of such in C1 through C6’s care binders besides, and to E-mail a copy of it LPA, by the POC due date. |
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14 | This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not develop an absentee notification plan for 6 of 6 clients (C1 through C6), which posed a potential health and safety risk to persons in care. | 8
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Type B
03/21/2025
Section Cited
CCR80061(b)(1)(E)
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7 | 80061 Reporting Requirements: “(b) Upon the occurrence, during the operation of the facility, of any of the events specified…below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.” | 1
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7 | CCLD is now aware of the circumstances leading up to C1 and C2’s respective absences from the facility. This resolves the deficiency. For completeness of records, Licensee agreed to send written incident reports describing C1 and C2’s absences to the CCLD San Diego Regional Office. |
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14 | This requirement was not met, as evidenced by: Based on records review and staff interviews, for 2 of 6 clients (C1 and C2), Licensee did not notify the licensing agency within the next working day and submit a written report within seven days following an unusual incident / client absence which threatened the physical health or emotional health of the client. This posed a potential health and safety risk to persons in care. | 8
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