425801940-10-7-2025-29-AS-MJES-DM8VSX-20251007164214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801940
Report Date: 10/07/2025
Date Signed: 10/07/2025 04:42:54 PM

Document Has Been Signed on 10/07/2025 04:42 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LYNN'S RCFE #2		FACILITY NUMBER:	425801940
ADMINISTRATOR/ DIRECTOR:	JOCELYN CHICO		FACILITY TYPE:	740
ADDRESS:	2730 SANTA BARBARA DRIVE		TELEPHONE:	(805) 623-8768
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY: 6		CENSUS: 4	DATE:	10/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator, Jocelyn Chico		TIME VISIT/ INSPECTION COMPLETED:	01:02 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	At 9:00am on 10/07/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA met with Administrator, Jocelyn Chico, announced who he is and the reason for the visit. This facility is a 5 bedrooms, 2 bathroom, two living rooms, ding room, kitchen, laundry room, and garage. Two bedrooms are double resident occupancy, the master is single resident occupancy with an on suite bathroom. The other bathrooms shared by all residents and staff. The 5th bedroom is a staff bedroom. There is a fenced yard in the back and with chairs and table under a umbrella for shad. There is sufficient room for activities and visiting, both inside and outside the facility. LPA observed duel smoke detectors and carbon monoxide detectors located throughout the facility that are hard wired and working properly. There is a fire extinguisher located in the laundry room that is primed and in the green. LPA noted the facility water temperature is within regulation perimeters of 105-120(f). LPA noted that there is a more than 72 hours of emergency water located in the garage. LPA note in the locked medication cabinet is located in the living room and a complete first aide kit is also located in the living room. LPA noted that all bedrooms have regulation required furnishings and linins. LPA noted that all bathrooms have liquid soap and paper towels. LPA noted that the facility was clean and in good repair and all exits, door ways, and passage ways were free and clear of obstacles. LPA conducted a cursory review of facility emergency disaster plan, infection control plan, staff files and training records, and client files. LPA noted that during the pre inspection review, LPA noted that the facility Incorporation was suspended and a citation was issued [87205(b)]. Additionally, during physical inspection LPA observed laundry door prompt open with chemicals unsecured and accessible to residents in care and a citation was issued [87309(a)(1). LPA conducted a full review of annual care tools and facility physical inspection. LPA noted no other violations or citations. Exit interview, report read, appeal rights and report provided.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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 10/07/2025 04:42 PM - It Cannot Be Edited

Created By: Mark Jeffries On 10/07/2025 at 11:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LYNN'S RCFE #2	FACILITY NUMBER: 425801940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87205(b)

Accountability of Licensee Governing Body

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review)], the licensee did not comply with the section cited above in having a suspend Inc., hich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2025
	Plan of Correction
1 2 3 4	Licensee will contact Secretary of State and get Incorporation current by 01/07/2025.

Type B

Section Cited

CCR

87309(a)(1)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 count of unsecured chemicles, ] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2025
	Plan of Correction
1 2 3 4	Licensee will keep laudrey room door secure at all time. Licesee with varifiy of securety with email by 10/07/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:

	Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC809 (FAS) - (06/04)

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