Facility Evaluation Report

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.