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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004779
Report Date: 06/19/2024
Date Signed: 02/11/2025 04:53:56 PM

Document Has Been Signed on 02/11/2025 04:53 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 IIIFACILITY NUMBER:
306004779
ADMINISTRATOR/
DIRECTOR:		MARICEL LINDSEYFACILITY TYPE:
740
ADDRESS:6533 VIA ESTRADATELEPHONE:
(714) 202-5075
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 5DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Larry LindseyTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit to the facility to complete the required Annual inspection. LPA Haley met with Licensee/Administrator Larry Lindsey and toured the facility.

The facility has a capacity of 6, of which 6 can be non-ambulatory and 1 may be bedridden. The facility phone number 714.202.5075.

Structure: The facility is one level structure with six bedrooms. Currently five bedrooms are being occupied by residents and 1 bedroom is being occupied by staff.
Kitchen: Sharps locked in a cabinet near the stove. A perishable food supply was observed in the refrigerator and freezer. Non-perishable food supply was observed in the cabinets.
Stove/Appliances:
There’s one stove with 4 burners and a warmer, a refrigerator, dishwasher, washer, and dryer. The top left burner, the warmer and the bottom right burner on the stove would not light unassisted.
Toxins: All cleaning supplies and chemicals are locked in the garage.
Medications, First-Aid Kit: Resident medications are locked in a closet near the front door. There’s a first aid kit in the kitchen.
Resident & Staff Files: Resident and staff records are kept in a cabinet behind the dining room table.
Bedrooms: Resident bedrooms were in compliance with regulation guidelines.
Bathrooms: The bathrooms have working toilets, wash basin and shower. Grab bars were tightly secured to the walsl.
Hot Water: Hot water was measured in the range of 115.8 – 119.1 degrees F.

Continued on LIC809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 306004779
VISIT DATE: 06/19/2024
NARRATIVE
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Hygiene Supplies: The facility has an adequate supply of hygiene items available.
Linens, Hygiene, Emergency Supplies: Additional linens for each resident are stored in a hallway closet.
Emergency Evacuation Drills: The most recent evacuation drill was conducted March 1, 2024.
Medication Review: There are currently five residents in the facility and medication was reviewed for all five residents.
Resident File Review: A file review was completed for all five residents.
Staff File Review: 3 staff files were reviewed during the visit.
Garage: Walkways were free of obstruction. A washer and dryer was observed. A refrigerator and an additional supply of non-perishable items were observed
Backyard: Clean, organized and walkways are free of obstruction. There's a table and chairs under a shaded patio area, and another table with a sunshade and chairs.
Smoke Detectors/Carbon Monoxide Detectors: Smoke detectors and the carbon monoxide detector tested operational. There’s a fully charged fire extinguisher on the counter behind the dining table.
Misc (P&I): N/A. The facility does not manage any of the resident’s money.
Activities, Recreation, Reading Material, etc: Puzzles, word search, exercise balls, clay the residents use.

Citation(s): Citations will be issued for violations observed during the inspection.
After the citation was written for the stove and dishwasher in disrepair, it was discovered the dishwasher is in good working condition. The outlet that the dishwasher was plugged into was not providing power to the dishwasher. The stove still needs to be repaired or replaced.

Exit Interview: Exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Larry Lindsey.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 04:53 PM - It Cannot Be Edited


Created By: Jerome Haley On 06/19/2024 at 11:58 AM
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 III
FACILITY NUMBER: 306004779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
87555 General Food Service Requirements

All equipment, fixed or mobile, and dishes, shall be kept clean and mainained in good repair and free of breaks, open seams, cracks, or chips.

This requirement is not met as evidenced by:
The stove and the dishwasher is in disrepair. The stove is missing knobs and two burners and the warmer will not light unassisted.
Deficient Practice Statement
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Based on observation, and interview confirmation, the licensee did not comply with the section cited above in which poses a potential health and safety risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee Larry Lindsey agrees to have the stove and the dishwasher replaced or repaired and email receipts of the repairs or replacements to LPA Haley by the POC due date.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
The screendoor on the sliding door that leads to the back yard in in disrepair. There's a large hole near the handle. There's oil on the knobs directly above the stove in the kitchen. Several spiders and spider webs were observed in the bathroom near bedrooms. Photos were taken of the stove, spiders, spider webs, and screendoor.
Deficient Practice Statement
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Based on observation and interview confirmation, the licensee did not comply with the section cited above, which poses a potential health and safety or risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Administrator Lindsey will have the screen door repaired or replaced, and agrees to have the kitchen and all bathrooms deep cleaned. Administrator will email LPA Haley of the repaired or replaced screen door, and photos of the bathroom and cabinets above the stove after the deep cleaning has been completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


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