306004712-11-17-2022-22-AS-LADS-CMSNVE-20230105094746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004712
Report Date: 11/17/2022
Date Signed: 11/17/2022 12:58:18 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/07/2022 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221007155537

FACILITY NAME:	ADELYA SENIOR HOME		FACILITY NUMBER:	306004712
ADMINISTRATOR:	LAWRENCE LINDSEY		FACILITY TYPE:	740
ADDRESS:	16912 SAGA DRIVE		TELEPHONE:	(323) 326-9062
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 5	DATE:	11/17/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Lawrence Lindsey		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Residents are not allowed to go to bed when they choose.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the findings on the complaint allegation above. LPA identified himself and discussed the purpose of the visit with staff.
The investigation into the allegation “Residents are not allowed to go to bed when they choose” revealed the following:

During the initial visit October 12, 2022 at 5:00 PM, LPA Haley discovered residents go to bed when they choose and residents tell staff where they (residents) want to be moved to (room, dining room, smoking area etc.). Further, LPA Haley received a description of a typical day for the caregivers and residents at the facility. All the information received during the visit contradicts the allegation above. LPA Haley made a second visit October 20, 2022 at 3:20 PM to follow up on the information received during the initial visit. During the second visit LPA Haley interviewed the remainder of the residents who were not interviewed during the initial visit. LPA noted the description of a typical day in the facility given during the initial visit was accurate.

Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221007155537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELYA SENIOR HOME	FACILITY NUMBER: 306004712
	VISIT DATE: 11/17/2022

NARRATIVE

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During the second visit, LPA Haley noticed the residents eating dinner, getting cleaned up, and watching TV in their bedroom. All residents were interviewed and three of the five residents confirmed that they go to bed when they choose and they were all pleased with the care provided at the facility.

Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegation: Residents are not allowed to go to bed when they choose, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC9099 (FAS) - (06/04)

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