Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Lydia “Lyn” Abille.

According to California Code of Regulations, Section 80075, medications which are centrally stored “shall be stored in [their] originally received container” and “no medications shall be transferred between containers.”

LPA observation of the facility’s medication cart, confirmed by interviews of multiple facility staff, showed: Prior to CCLD's intervention, Licensee’s standard practice was to remove clients’ centrally stored medications from their labeled blister packs (i.e., the packages in which the pills/tablets arrived from the pharmacy), up to three (3) days in advance of administration time, and to transfer them to plastic cups. These cups were not labeled with either clients’ names or other identifying information. These cups were then stacked directly on top of one another. Multiple stacks of cups were observed beside each other, within the same drawer of the facility’s medication cart, pending medication administration.

The above deficient practice was applied to the four (4) clients in care. On 01/15/2025, this practice materially contributed to medication errors by made Staff #1 (S1) and impacting Client #1 (C1), for which Licensee was separately-cited as part CCLD’s complaint investigation. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Lydia “Lyn” Abille, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.