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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602902
Report Date: 03/24/2025
Date Signed: 03/26/2025 03:16:28 PM

Document Has Been Signed on 03/26/2025 03:16 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 IIIFACILITY NUMBER:
374602902
ADMINISTRATOR/
DIRECTOR:		ABILLE, LYDIAFACILITY TYPE:
735
ADDRESS:186 MOSS STTELEPHONE:
(619) 426-2804
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
03/24/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:28 AM
MET WITH:Licensee Lydia "Lyn" AbilleTIME VISIT/
INSPECTION COMPLETED:
07:00 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 03/21/2025. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Lydia "Lyn" Abille.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of whom all must be ambulatory. According to LIC602 Physician’s Reports, staff interviews, and LPA observation: At the start of this annual inspection, there were a total of six (6) clients in care, and all were ambulatory, per their respective doctors. (One of these clients had moved out by the date of CCLD’s return visit). The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During this inspection, LPA toured the interior and exterior of the facility and inspected all common areas and bedrooms. LPA interviewed multiple clients and multiple staff. LPA also reviewed the care and administrative records for all clients and the personnel and training files for all active staff. The facility was in good repair, but unclean in some areas. (This issue was addressed/cited in a separate LIC9099 visit report delivered the same day.) 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 had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.


[CONTINUED ON LIC 809-C, 1 of 2]

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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 6
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)
Page: 2 of 6
Document Has Been Signed on 03/26/2025 03:16 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/24/2025 at 03:53 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 III
FACILITY NUMBER: 374602902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 possess a completed and signed health screening for 2 of 6 staff (S1 and S2). This posed a potential health and safety risk to 6 of 6 clients (Client #1 through Client #6) in care.
POC Due Date: 03/24/2025
Plan of Correction
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As of the date of deficiency issuance, S1 and S2 are still on the employee roster but both are on a leave of absence overseas. Licensee agreed to keep S1 and S2 off duty until each completes a LIC503 Health Screening with negative tuberculosis (TB) test result. This resolves the deficiency.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 ensure that 2 of 6 staff (S1 and S2) had tuberculosis test documents within their personnel records. This posed a potential health risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 03/24/2025
Plan of Correction
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As of the date of deficiency issuance, S1 and S2 are still on the employee roster but both are on a leave of absence overseas. Licensee agreed to keep S1 and S2 off duty until each completes a LIC503 Health Screening with negative tuberculosis (TB) test result. This resolves the deficiency.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/26/2025 03:16 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/24/2025 at 03:53 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 III
FACILITY NUMBER: 374602902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records and interviews, Licensee did not ensure that 6 of 6 staff (S1 through S6) had current first aid training from a qualified agency. This posed a potential health and safety risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 04/24/2025
Plan of Correction
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Licensee agreed to have S1 through S6 complete First Aid Training from a qualified agency. Licensee agreed to E-mail the updated First Aid Certification cards for S1 through S6 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
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 III
FACILITY NUMBER: 374602902
VISIT DATE: 03/24/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility’s ambient internal temperature was complaint at 70 F. Hot water temperature at taps accessible to clients was initially too cold: Kitchen Sink was 102.4 F and Bathroom Sink was 100.9 F. (This issue was addressed/cited in a separate LIC9099 visit report delivered the same day.) During today’s visit, adjustments were made to the facility’s water heater, which brought both taps back into the complaint temperature range. Refrigerators and freezers used to preserve perishable food were complaint in temperature. There were at least (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 and in good condition.

The facility did not have a swimming pool (or similar body of water) or a fireplace. There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguisher was serviced within the last twelve (12) months. Medications were in their original pharmacy packaging and were stored in a locked medication cart. 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.

During a review of records, LPA observed, and manager interview confirmed: Licensee did not ensure that Staff #1 (S1) and Staff #2 (S2) had a completed their respective LIC503 Health Screening (or equivalent pre-employment physical exam), as required. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Licensee also did not ensure that S1 and S2 each had a negative tuberculosis (TB) test result/screening, which was required before they started working. Licensee also did not maintain proof of current First Aid training/certification for S1 through Staff #6 (S6) in their personnel files, as required.



[CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
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 III
FACILITY NUMBER: 374602902
VISIT DATE: 03/24/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

As part of this annual inspection visit, three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA issued one (1) Technical Violation regarding disaster drills, and Technical Assistance (TA) regarding obtaining an updated Medical Assessment for Client #1 (C1) and regarding refresher training for staff on Mandated Reporting requirements.

An exit interview was conducted with Licensee Lydia "Lyn" Abille, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6