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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004762
Report Date: 07/14/2025
Date Signed: 07/14/2025 04:42:20 PM

Document Has Been Signed on 07/14/2025 04:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ADELYA SENIOR HOME IIFACILITY NUMBER:
306004762
ADMINISTRATOR/
DIRECTOR:		LAWRENCE LINDSEYFACILITY TYPE:
740
ADDRESS:16419 VERNON STREETTELEPHONE:
(657) 218-4680
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
07/14/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Emelda Estrella, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On July 14, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required continuation annual visit. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Imelda Estrella. LPA spoke with Licensee (LI) Lawrence Lindsey over the phone and explained the purpose of the visit. LI Lindsey said they could not attend today’s visit and CG Estrella can sign for the report on their behalf.

LPA Bentley toured inside and outside of the physical plant with CG Estrella. The resident bedrooms were inspected and contained all the required elements. Bathrooms were found to be clean and operational, however, there were no slip mats available at the time of the initial tour.

During today’s visit, interviews were conducted with five (5) residents and one (1) staff during today’s visit. Medication and Medication Administration Record (MAR) reviewed. LPA Bentley conducted an audit of five (5) resident files (R1-R5) and three (3) staff files (S1-S3). Based on observation, interview, and record review, licensee did not ensure annual training was complete/up-to-date for three staff members, three residents do not have bed rail orders on record, Needs and Appraisal forms are incomplete for five residents, Centrally Stored Medication Administration Record is incomplete, Slip mats were missing in three bathrooms and later provided.

Based on today’s observations, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted and a copy of this report, LIC809-D, Technical Violations, and appeal rights were provided to Caregiver (CG) Imelda Estrella.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/14/2025 04:42 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/14/2025 at 02:14 PM
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: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in thre out of five resident records, which poses a potential health and safety risk to persons in care.
POC Due Date: 07/22/2025
Plan of Correction
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Licensee stated that the Physician's Bed Rail orders will be obtained and will submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
87705(b)(1)(A)
(b) Licensees shall be responsible for the following:
(1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (A) Dementia care, including, but not limited to, knowledge about hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, licensee did not ensure current training was completed in three out of three staff, which poses a potential Health, Safety, and Personal Rights risk to persons with Dementia in care.
POC Due Date: 07/22/2025
Plan of Correction
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Licensee stated that annual training and CPR certifications will be completed and submitted to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2025 04:42 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/14/2025 at 03:33 PM
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: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited by completing a current Needs & Services Plan in five out of the five resident records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2025
Plan of Correction
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Licensee stated they will review and complete all resident Needs & Service Plans and submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
87465(h)(6)(A-F)
Incidental Medical and Dental Care Services. Licensee shall be responsible for assuring that a record of centrally stored
prescription medications for each resident is maintained for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of the centrally stored medication form & MAR, the licensee did not comply with the section cited above in
five out of five resident records, which poses a potential health and safety risk to persons in care. Based on Resident
medication and record review, the licensee failed to update/document five resident records of centrally stored
prescription medications for each resident and MARs.
POC Due Date: 07/22/2025
Plan of Correction
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Licensee will ensure all resident MARs contain a record of centrally stored medications for all residents in care and sign off on each medication administered, effective immediately. Licensee stated they will review regulations and re-train the facility staff on how to accurately record resident medications. Licensee stated they will email LPA the content covered in the training, training attendees and the date and time of training and email to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2025 04:42 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/14/2025 at 04:28 PM
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: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure three out of three showers had non-slip mats, which poses a potential safety risk to persons in care.
POC Due Date: 07/22/2025
Plan of Correction
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Licensee stated they will install non-slip mats and submit proof to LPA by POC due date. Licensee purchased mats and placed in all showers during visit.
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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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