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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004779
Report Date: 03/12/2026
Date Signed: 03/12/2026 03:49:15 PM

Unsubstantiated


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
06/27/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250627101345
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:
03/12/2026
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Larry Lindsey, LicenseeTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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-Neglect / Lack of adequate care from staff resulted in resident sustaining multiple pressure injuries.
-Staff providing care beyond the scope of the license (wound care).
-Staff did not provide resident linens.
-Staff did not ensure resident's toileting needs were met.
-Staff did not ensure resident was provided daily activities.


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry to the facility by Larry Lindsey, Licensee and LPA stated the purpose of the visit.

An initial investigation visit was conducted on June 30, 2025. During the visit, LPA Vanegas conducted a tour of the facility, and observed all residents, resting in their respective rooms and the common areas of the facility. LPA Vanegas gathered and reviewed pertinent records pertaining to residents in care in regard to the allegations stated above. LPA Vanegas interviewed one resident as four different residents were not available for interview. Furthermore, LPA Vanegas interviewed the administrator, and three different staff members.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
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-20250627101345
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: 03/12/2026
NARRATIVE
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It is alleged that neglect / Lack of adequate care from staff resulted in resident sustaining multiple pressure injuries, specifically to feet, ankle, buttocks, hip and back. Record review revealed that resident (R1) had an order summary report at Town & Country SNF on May 24, 2022, with the following: rehab and evaluation for treatment are as follows, heel protector of heel, (TX) of coccyx, left groin, right groin, skin, bilateral heel, discoloration of bilateral lower extremities, and upper extremities as of 5/13/22. R1 was admitted to the facility on June 7, 2022. Functional capabilities assessment reflects reposition from side to side. Admissions records for Providence Home Health dated May 18, 2024, admissions diagnoses are pressure ulcer of left ankle stage 2, pressure ulcer of left heel unstageable, kidney disease, atrial fibrillation, thrombophilia, dysphagia, vascular disease, atherosclerosis of aorta, degenerative disease of nervous system, anxiety, and personal history of other diseases of circular system. Interviews with 2 of 2 staff stated that R1 had closed wounds and staff would apply ointment and/or bandages to them. Interviews conducted revealed that staff 2 of 2 stated that R1 did not have the wounds prior to entering the facility. Staff 4 of 4 stated that residents are rotated every two hours. Interview with residents stated that they are unaware of residents getting rotated because they don’t go into that resident’s room. Staff treat residents with dignity and respect.

It is alleged that staff providing care beyond the scope of the license revealed the following. No dates or times were provided of when the alleged violation took place. It was reported that staff on duty provide wound care for R1’s pressure injuries sustained while under the supervision of the facility. Interviews with 4 of 4 staff did not corroborate the allegation. All staff stated that they provided sanitation of the wound if needed by applying ointment and bandages. R1 was admitted to home health and they provided wound care. Interview with resident stated that they have never witnessed any wound care treatment being performed on any resident.

It is alleged that staff did not provide resident linens. It was reported that staff on duty denied a linen for R1 due to R1 getting the linens dirty too frequently. Interviews with 4 of 4 staff did not corroborate the allegation, it was stated that if a resident requires changing or cleaning, they provide that service right away. Interview with resident revealed the following, if clean linens are needed, they will receive them right away.

Continued on LIC9099-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20250627101345
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: 03/12/2026
NARRATIVE
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It is alleged that staff did not ensure that the residents’ toileting needs were met. It was stated that resident was observed to be soiled on several occasions, and they were changed only when it was brought to the staff’s attention. Interviews with 4 of 4 staff revealed that they change residents whenever it is observed that they have a soiled diaper. Interview with resident revealed that they have never witnessed any residents sitting in a soiled diaper.

It is alleged that staff did not ensure resident was provided daily activities, specifically to staff leaving R1 in their room with no stimulation such as the television being on. Interviews with 4 of 4 staff revealed that the facility offers activities, however the residents do not like to take part in the activities. Interview with resident revealed the following that the facility does offer activities, however they do not like to participate in many activities.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated.

An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3