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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004779
Report Date: 09/25/2025
Date Signed: 09/25/2025 11:36:23 AM

Document Has Been Signed on 09/25/2025 11:36 AM - 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: 4DATE:
09/25/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:31 AM
MET WITH:Larry and Maricel Lindsey, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit for the purpose of completing a Case Management Deficiency. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit.

During the investigation for complaint control number 22-AS-20250414124920, the following deficiencies were observed.

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. 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.

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.

(Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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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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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: 09/25/2025
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(Continued from LIC 809)

Licensee reported he was unaware if R1 had a pendant to call for help. Per pre-appraisal dated March 10, 2025, R1 did not require observation at night and was not documented as a known fall risk. Facility conducted a reappraisal on April 4, 2025, and documented R1 did not need special observation/night supervision due to confusion, forgetfulness, and wandering, despite having knowledge that R1 was exhibiting wander behavior at night. At no point did the facility update R1’s appraisal to document R1’s new behaviors and implement a plan to meet R1’s needs.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with Larry and Maricel Lindsey, Administrator, and a copy of this report, 809-D, LIC811 Confidential Names List and Appeal Rights were left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 03:05 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/07/2025 02:46 PM


Created By: RoseMarie Ruppert On 09/25/2025 at 10:55 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
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
87465(g)

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Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Licensee and Administrator will review regulations pertaining to the deficiences and will conduct a staff inservice on 9-1-1 protocol. Licensee emailed LPA with in-service documentation, signed by staff, by POC date.
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This requirement was not met as evidenced by: On May 13, 2025 R1 had a ground level fall and staff did not immediately call 911. This poses an immediate health and safety risk to residents in care.
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Type A
09/26/2025
Section Cited
CCR87463(b)

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87463 Reappraisals: (b)The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement was not met
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Licensee and Administrator will review regulations pertaining to the deficiences and will conduct a staff inservice on re-assessment and re-appraisal documentation.. Licensee emailed LPA with in-service documentation signed by staff, by POC date.
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as evidenced by: Licensee did not document R1’s wander behavior or fall risk on reappraisal completed despite being aware of behavior. As a result, R1 sustained a fall resulting in hospitalization and fracture. This poses an immediate safety risk to residents 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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