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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004762
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:56:02 PM

Document Has Been Signed on 07/12/2021 03:56 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 HOME IIFACILITY NUMBER:
306004762
ADMINISTRATOR:LAWRENCE LINDSEYFACILITY TYPE:
740
ADDRESS:16419 VERNON STREETTELEPHONE:
(657) 218-4680
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 2DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Imelda EstrellaTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Imelda Estrella and explained the reason for the visit.

At 11:25 AM, LPA toured the facility with Caregiver Imelda Estrella. Facility has 2 residents during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. At 11:35 AM, LPA observed unsecured prescription and over the counter medications in the unlocked caregiver room. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily. Facility has covid precaution postings as well as all required department postings. Lawrence Lindsey has an administrator certificate expiring on 12/25/2021. The facility mitigation plan has been completed and approved. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed ample shaded outside visitation area. Exit gate is unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files which contained all required documentation including updated emergency information.

LPA consulted with Caregiver regarding the importance of maintaining a thirty day supply of PPE at all times and documenting all temperatures taken in the facility as well as ensuring all medications in the facility are secured at all times. Additionally, LPA and caregiver spoke on the importance of posted hand washing signs in all restrooms.
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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 07/12/2021 03:56 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/12/2021 at 11:58 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 II
FACILITY NUMBER: 306004762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured prescription medications as well as over the counter medications unsecured in the unlocked caregiver room. Resident 2's pre-appraisal dated 03/02/2020 indicates a diagnosis of Dementia. This poses an immediate health and safety risk to persons in care.
POC Due Date: 07/13/2021
Plan of Correction
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Licensee to secure items and forward proof to LPA by POC due date.
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:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021


LIC809 (FAS) - (06/04)
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