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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602902
Report Date: 05/24/2023
Date Signed: 06/14/2023 01:34:06 PM

Document Has Been Signed on 06/14/2023 01:34 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 IIIFACILITY NUMBER:
374602902
ADMINISTRATOR:ABILLE, LYDIAFACILITY TYPE:
735
ADDRESS:186 MOSS STTELEPHONE:
(619) 426-2804
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
05/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator Lydia AbilleTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted a Case Management Visit during an unannounced Complaint Visit. LPA met with Administrator Lydia Abille and discussed the purpose of the visit.

During a complaint investigation, LPA discovered, that facility did not keep records for previous Client 1 (C1) who moved out on or about 2021.

Based on this information, a deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. An exit interview was conducted and a copy of the report, Licensee/Appeal Rights (LIC9058 03/22) and LIC811 were provided to Administrator Lydia Abille.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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 06/14/2023 01:34 PM - It Cannot Be Edited


Created By: Iby Strong On 05/24/2023 at 10:33 AM
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: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2023
Section Cited
CCR
80070(g)

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80070 Client Records (g) Original client records or photographic reproductions shall be retained for at least three years following termination of service to the client..

This requirement was not met as evidence by:
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Administrator agrees to review regulations regarding records and submit a verification letter to LPA by 6/7/2023
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Based on interview and observations the licensee did not maintain client record in one of six persons in care ([C1]) which posed a potential Personal Rights risk to persons in care
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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:John Rante
LICENSING EVALUATOR NAME:Iby Strong
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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