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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004779
Report Date: 07/11/2025
Date Signed: 07/11/2025 02:32:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/06/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20250706214148
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: 4DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Maisyarah SumantriTIME COMPLETED:
02:47 PM
ALLEGATION(S):
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Staff did not provide access to a resident's record
Staff did not properly sanitize the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to conduct an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged staff did not provide access to a resident's record and staff did not properly sanitize the facility. During the investigation, LPA conducted interviews with staff and residents in care and reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff did not provide access to a resident's record, it was reported the facility did not allow the visiting Ombudsman access to Resident 1 (R1)'s medical record even though the Ombudsman had obtained written consent from R1 on June 30, 2025. LPA interview with R1 stated they provided consent to the Ombudsman. LPA showed a copy of the signed consent form to R1 and R1 confirmed they signed the consent form.
Continued on 9099-C dated 07/11/2025
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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 3
Control Number 22-AS-20250706214148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/11/2025
NARRATIVE
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R1 stated Ombudsman wanted to review their medical information due to a discussion had between R1 and the Ombudsman on June 30, 2025. R1 stated they later rescinded the consent verbally over the phone with the Ombudsman hours after the Ombudsman left the facility. LPA interviews with two out of two staff interviewed stated during the visit on June 30, 2025, the Ombudsman asked to view R1's medical records. Two out of two staff stated they declined to provide medical records to the Ombudsman even with R1's written consent. One out of two staff added they told the Ombudsman they needed consent from R1's family member in order to provide R1's records. Ombudsman along with Staff 1 (S1) called the Department's duty line to discuss the matter and spoke with LPAs Garlli Tat and Kevin Saborit-Guasch during the Ombudsman visit at the facilty. Both on duty LPAs explained to S1 that in the absence of a conservatorship, R1 could agree to share their personal information with the Ombudsman as part of their duties at the facility. S1 acknowledged that after the phone call with the on duty LPAs, S1 still declined to share R1's medical record with the Ombudsman while the Ombudsman was at the facility. The Ombudsman never obtained R1's medical records. LPA record review of R1's file did not indicate a conservatorship nor any power of attorney documents in place.

Regarding the allegation staff did not properly sanitize the facility, it was reported there is a strong urine odor at the facility. LPA Arias observed a lingering urine odor coming from the living room. LPA observed a very strong urine odor coming from Resident 2 (R2)'s room. LPA interview with staff 2 (S2) stated R2 is not cognitive and urinates on different places in the room including on the wood floor. R2 has to be redirected to use the bathroom. LPA observed some of the wood flooring has warped in R2's room. S2 stated they mop the floor often but that does not remove the urine odor.

Based on LPA interviews, observations, and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250706214148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2025
Section Cited
CCR
87506(c)(1)
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87506(c)(1) Resident Records
The licensee and all employees shall...make available confidential information only upon the resident's written consent or that of his designated representative.
This requirement is not met as evidenced by:
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Licensee stated he will provide a signed statement of understanding on regulation 87506(c)(1) and email LPA by POC due date.
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Based on LPA interviews and record review, the licensee did not comply with the section cited above for Resident 1 which posed a potential personal rights risk to persons in care.
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Type B
08/08/2025
Section Cited
CCR
87303(a)
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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenanace shall include provision of maintenanace services and procedures for the safety and well-being of residents, employees and visitors
This requirement is not met as evidenced by:
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Licensee stated they will contract a cleaning company to clean the flooring or replace flooring with tile and provide proof to LPA by POC due date.
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Based on LPA interviews and observations, the licensee did not comply with the section cited above for Resident 2's room which poses a potential health, safety and personal rights risk to persons in care.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3