<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004779
Report Date: 09/25/2025
Date Signed: 09/25/2025 11:21:35 AM

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
04/14/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250414124920
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:
09/25/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maricel Lindsey, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injury while in care due to lack of care and supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit.

It was alleged resident sustained unexplained injury while in care due to lack of care and supervision. During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed medical records from the University of California Irvine (UCI) Medical Center. The investigation revealed the following:

Resident #1 (R1) was admitted to the facility on April 4, 2025. Per Physician report dated March 25, 2025, R1 had a diagnosis of Dementia. Physician report further assessed R1 had motor impairment/ paralysis, confused and disoriented and was non-ambulatory.
(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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 4
Control Number 22-AS-20250414124920
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: 09/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from LIC 9099)

On May 13, 2025, Resident #1 (R1) had an unwitnessed ground level fall. It is unknown what time of night this fall occurred. Two of two Staff interviewed stated R1 was put to bed between 8pm and 9pm and was not checked on until the next morning. Per interviews with two of two staff & Licensee, the facility does not have awake staff at night. At 8:15am on May 14, 2025, Staff #1 (S1) and Staff #2 (S2) found R1 on the floor with a cut above R1’s left brow. Staff picked R1 up from the ground and placed R1 in a wheelchair. Staff then proceeded to clean the bedroom of the blood on the floor. After cleaning the room, staff contacted the Licensee Lawrence Lindsey, who then called 911. Hospital records obtained show Paramedics were dispatched at 9:02am and arrived on scene at 9:07am. Due to S1 and S2 not immediately calling 9-1-1 there was an approximate 52 minute delay in R1 receiving medical attention.

Paramedics reported that upon arrival, R1’s room was cleaned of blood but the resident was covered in dried blood on their hair, face and body. R1 was transferred to UCI Medical Center after paramedics observed a hematoma with 2 cm laceration to the head; and scattered bruising in various signs of healing on R1. Per medical records obtained, R1 was diagnosed with a closed fracture to a right rib; subdural hematoma; intraventricular hemorrhage; impaired mobility; and dementia.

Per R1’s family, R1 has had a history of recurrent falls since December 2024 and correlating with Urinary Tract Infections (UTIs). Family informed Licensee that R1 wandered at night and had been working with R1’s Primary Care Physician to manage insomnia with medications. During interview with Licensee, Licensee acknowledged knowing R1 had a tendency to wander at night and was a fall risk. Despite, knowing R1’s wander behavior, no additional staff was provided to ensure R1’s safety while wandering. When asked about fall prevention methods, Licensee stated a fall mat had not been implemented due to R1’s family not providing one and was unaware if bedrails had been ordered for R1. Licensee reported they were unaware if R1 had a pendant to call for help. R1 was discharged to a Hospice Facility where they passed away on April 29, 2025. Per Death Certificate, R1’s cause of death is listed as traumatic intraventricular hemorrhage.

Based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegation that the Resident sustained unexplained injury while in care due to lack of care and supervision is substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

(Continued on LIC 9099-C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250414124920
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: 09/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from LIC 9099-C)

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e)

An exit interview was conducted with Maricel Lindsey, Administrator, and a copy of this report, 9099-D, LIC421IM, LIC811 Confidential Names, and Appeal Rights were left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250414124920
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: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2025
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Staff placed R1 to bed
1
2
3
4
5
6
7
Licensee and Administrator will review regulation pertaining to the deficiences cited and will conduct a staff inservice on Basic Services to be provided to residents in care. Licensee completed POC and emailed LPA with in-service documentation, signed by staff, by POC date.
8
9
10
11
12
13
14
between 8-9pm on May 12, 2025 and did not check on R1 until May 13, 2025 at 8:15am. This poses an immediate health and safety risk to residents in care. A civil penalty will be assessed.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4