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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004712
Report Date: 04/11/2022
Date Signed: 04/14/2022 01:22:52 PM

Document Has Been Signed on 04/14/2022 01:22 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ADELYA SENIOR HOMEFACILITY NUMBER:
306004712
ADMINISTRATOR:LAWRENCE LINDSEYFACILITY TYPE:
740
ADDRESS:16912 SAGA DRIVETELEPHONE:
(323) 326-9062
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennylyn MagetTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted this unannounced required/annual inspection. LPA was greeted by caregiver Ugene and Jennylyn Maget. Administrator (AD) Larry Lindsey was contacted by phone but could not be present stating they were out of town. LPA Gutierrez discussed the purpose of the inspection with AD over the phone and present caregivers. AD stated caregivers would be able to complete inspection. During the inspection LPA and caregivers conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a single-story house with five bedrooms and two bathrooms, with one bedroom being used for live-in staff. During the inspection, LPA observed there were 2 staff present and 5 residents in care. Residents were observed relaxing watching tv in the living room and in their respective bedrooms. LPA inspected common areas, resident rooms, kitchen, and garage and observed a 2-day supply of perishables and a 7-day supply of non-perishable food is available. LPA observed hallways and walkways were free of obstruction. Resident files were also review and three of five resident files were found to have incomplete emergency contact information; a deficiency was cited on this day.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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 04/14/2022 01:22 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/11/2022 at 10:24 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELYA SENIOR HOME
FACILITY NUMBER: 306004712

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of five resident files which poses a potential health and safety risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Facility needs to update forms and email LPA Claudia Gutierrez a copy of forms completed by 04/15/2022.
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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022


LIC809 (FAS) - (06/04)
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