<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004762
Report Date: 09/18/2023
Date Signed: 09/18/2023 09:48:18 AM

Document Has Been Signed on 09/18/2023 09:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 4DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Imelda EstrellaTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual inspection. LPA arrived at facility was greeted at the door by Imelda Estrella, caregiver and granted entry. Four residents currently reside at this location and hospice services are being provided to two residents at this time.

LPA accompanied by caregiver began the tour of the inside and outside of the facility which is a one-story home with an attached garage. LPA observed that the facility stays within the capacity limitations. There are no bodies of water or firearms at this location. There is a minimum of one week of non-perishable foods and two days of perishable foods available. There is additional food storage in attached garage freezer. The facility is maintained at a comfortable temperature and the water temperature measures 119.8 Fahrenheit degrees in facility bathrooms. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars Lighting is sufficient to ensure safety and comfort. The facility provides personal hygiene items such as soap, toilet paper, toothbrush, and toothpaste. The facility has an available a clean supply of linen. Storage space is provided for residents. LPA inspected resident’s bedrooms which had sufficient lighting to ensure safety and comfort. LPA checked if medications are centrally stored in a safe locked storage closet location in kitchen room. LPA inspected and observed that toxic chemicals, cleaning solutions and disinfectants are locked and inaccessible to residents in care. Smoke detectors and alarms were tested and operational. LPA toured the outside parameters of facility and observed outdoor passageways are free of obstruction. All employees have a criminal record clearance. LPA spoke with alert residents during regarding the quality of their care. During the inspection, LPA reviewed four resident records, and one staff record.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with caregiver, and a copy furnished to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1