306004762-3-20-2023-22-AS-LADS-CQBK5X-20230327073640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004762
Report Date: 03/20/2023
Date Signed: 03/20/2023 12:59:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230317121845

FACILITY NAME:	ADELYA SENIOR HOME II		FACILITY NUMBER:	306004762
ADMINISTRATOR:	LAWRENCE LINDSEY		FACILITY TYPE:	740
ADDRESS:	16419 VERNON STREET		TELEPHONE:	(657) 218-4680
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 4	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Caregiver- Imelda Estrella		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Facility is dirty.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Celine De Perio made an unannounced complaint visit to the facility to initiate the 10-day visit for the complaint received on 3/17/23 and to deliver the findings. LPA was greeted and granted entry by staff on duty, who contacted facility administrator (AD) Lawrence "Larry" Lindsey about visit. AD was unable to be present during time of visit, however, provided consent for staff on duty (S1) Imelda Estrella to receive and sign report.

For today's visit, there are a total of 4 residents in care of which 3 are on hospice. LPA conducted a tour of the interior and exterior portion of the facility with S1, conducted record reviews, interviews and obtained copies of pertinent documents.

This department has investigated the complaint alleging that the facility is dirty.

SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230317121845

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 II	FACILITY NUMBER: 306004762
	VISIT DATE: 03/20/2023

NARRATIVE

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During the tour, LPA observed all resident rooms, caregiver room, bathrooms, living room, dining area and kitchen to be clean, in good repair, and free of odors. During LPA's arrival at the facility, staff on duty were observed to be cleaning the kitchen.

LPA conducted a total of 7 interviews, which consisted of staff and residents, and 7 out of the 7 interviews did not corroborate with the allegation.

LPA conducted record reviews such as, but not limited to: the facility admission agreement, staff schedule, staff roster, and the resident roster. Facility does not have any documents regarding cleaning procedures, cleaning schedule and cleaning tasks.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

For today's this visit, an advisory was issued, and no citations issued.

An exit interview was conducted with S1 and AD via telephone call, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

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