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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004779
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:06:39 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
09/04/2020 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200904122808
FACILITY NAME:ADELYA SENIOR HOME IIIFACILITY NUMBER:
306004779
ADMINISTRATOR:MARICEL LINDSEYFACILITY TYPE:
740
ADDRESS:6533 VIA ESTRADATELEPHONE:
(714) 202-5075
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 6DATE:
08/20/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maricel LindseyTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a pressure injury while in care.
Facility refused medical services for resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Administrator Maricel Lindsey. The investigation consisted of interviews with Administrator and witnesses as well as documentation. The following was determined:
Resident #1 was admitted into the facility in October 2016. Records reviewed disclosed that R1 developed a Stage 1 pressure injury and was referred to home health on 7/6/20 by her medical provider. Home Health visited R1 at the facility in September. According to staff interviewed, R1 has had Health Services several times since 7/20/2020 for wound care and physcial.
Based upon interviews and a review of records, the allegations above are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that R1 developed a Stage 1 pressure injury due to neglect or that the facility staff refused medical services. Licensee is reminded that residents shall always receive care as ordered by their doctor.
An exit interview was conducted and a copy of this report was provided to Maricel Lindsey.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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