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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004779
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:21:47 PM

Substantiated


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
11/08/2023 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231108125250
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: 5DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Maricel Lindsy - DirectorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Facility failed to report resident’s fall and injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received November 8, 2023. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Director Maricel Lindsy was contacted via telephone and arrived shortly after and was present for the remainder of the visit.
Regarding the allegation: Facility failed to report resident’s fall and injury.
During an interview with Director Lindsy it was confirmed no incident report was sent to the Region Office regarding Resident 1's fall and injury. Interviews with Director Lindsy, facility staff, Resident 1's son-in-law, R1's physician, and hospice provider confirmed R1 had an unwitnessed fall and sustained an injury to the hip. A review of Angels Hospice RN/LVN Communication Flow Sheet revealed R1 fell on October 18, 2023.
Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6.
An exit interview was conducted and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20231108125250
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 III
FACILITY NUMBER: 306004779
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) a written report shall be submitted to the licensing agency... within seven days... (D) Any incident which threatens the welfare, safety, or health of any resident, such as... or unexplained absence of any resident.
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Director Maricel Lindsy will review Regulation Section 87211 (Reporting Requirements) and email a plan of action that will prevent a failure to report in the future. The plan will include who will be responsible for sending incident reports to the Regional Office.
POC due date: November 22, 2023 at 1:00 PM.
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This requirement is not being met as evidenced by interview confirmation with Director Lindsy that an incident report was not completed and sent to the Regional Office. Multiple interviews and a review of a Hospice document titled "RN/LVN Communication Flow Sheet" reveal R1 had an unwitnessed fall and sustained an injury October 18, 2023.
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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.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
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