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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004779
Report Date: 06/16/2025
Date Signed: 06/16/2025 05:31:47 PM

Document Has Been Signed on 06/16/2025 05:31 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:
06/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Caregiver - Connie MartinezTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On June 16, 2025, at 1:00pm, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced
required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was
greeted and granted entry by Caregiver (CG) Connie Martinez after explaining the purpose of the visit. Administrator Lawrence Lindsey was contacted by telephone and stated he was available by phone, as needed. AD Lawrence Lindsey has an administrator certificate with an expiration date of December 25, 2025.

The facility is licensed to operate for six (6) non-ambulatory, of which one (1) may be bedridden and a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, an attached garage, and outside covered patio area. There are five residents on census, all present during today’s visit. LPA obtained copies of pertinent documents, including facility records, clients/staff rosters and Personnel Record (LIC500).

During the visit, LPA Bentley toured the interior and exterior of the physical plant with CG Martinez and observed the facility to be appropriately furnished at the time of visit. Sharp objects were stored and locked. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available. LPA observed unsanitary conditions in the kitchen and bathroom, the garage full of storage and clutter, and there is only one exit gate in the backyard, which is in need of repair. LPA also observed multiple areas in the garage where toxins are stored in the same area as food items.

CONTINUE TO LIC 809-C PAGE...
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
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 5
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 06/16/2025 05:31 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/16/2025 at 04:35 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 III
FACILITY NUMBER: 306004779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in one out of five resident Physician's Reports. Resident #1 has an incomplete Physican's Report with primary diagnosis missing from page 2 and date next to Physician's signature.
POC Due Date: 06/30/2025
Plan of Correction
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Licensee will schedule visit with physician and resident to obtain complete report and email updated Physican's Report to LPA by POC due date.
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care. LPA observed unsanitary conditions in the kitchen and bathroom, the garage full of storage and clutter, and there is only one exit gate in the backyard, which is in need of repair. LPA also observed multiple areas in the garage where toxins are stored in the same area as food items.
POC Due Date: 06/30/2025
Plan of Correction
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Licensee will have the exit gate repaired or replaced, have a deep cleaning of the kitchen and all bathrooms, organize/remove clutter in garage, and remove all toxins from areas where food is stored. Licensee will email LPA Bentley photos of the repaired/replaced exit gate, cleaned kitchen, bathrooms and garage 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: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2025 05:31 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/16/2025 at 04:57 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 III
FACILITY NUMBER: 306004779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 an immediate health and safety risk to persons in care. Based on medication and record review, the licensee did not document medication administered to all residents since 6/6/2025.
POC Due Date: 06/30/2025
Plan of Correction
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Licensee will ensure all resident MARs contain a record of each medication pas for all residents in care, effective immediately. Licensee will review regulations and re-train the facility staff on how to accurately record resident medications passes. Licensee will email LPA the content covered in the training, training attendees and the date and time of training aby POC due date.
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: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2025


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: 06/16/2025
NARRATIVE
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Emergency safety drills were last conducted on March 1, 2025 and are completed on a quarterly basis. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were tested and observed
operational. The facility has one (1) fire extinguisher that is fully charged in the kitchen, with a last service date of March 30, 2025. Liability Insurance is effective July 1, 2024 through July 1, 2025.

Interviews were conducted with four (4) residents and two (2) staff during today’s visit. Medication and Medication Administration Record (MAR) reviewed. Based on medication and record review, the licensee did not document medication administered to all residents since 6/6/2025. LPA Bentley conducted an audit of five (5) resident files (R1-R5) and three (3) staff files (S1-S3). Resident #1 has an incomplete Physican's Report with primary diagnosis missing from page 2 and date next to Physician's signature.

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

LPA spoke with Administrator Lawrence Lindsey by phone, an exit interview was conducted and a copy of this report, and LIC809-D was provided to Caregiver Connie Martinez.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
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