306004712-2-20-2024-22-AS-JHAY-D2N2ZU-20240220165055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004712
Report Date: 02/20/2024
Date Signed: 02/20/2024 04:51:10 PM

Document Has Been Signed on 02/20/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	02/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Imelda Martinez Ferdinand Baquiran		TIME COMPLETED:	05:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Licensee/Administrator (AD) Lawrence “Larry” Lindsey was contacted via telephone.

Adelya Senior Home is a one-story community with five bedrooms and two bathrooms. The facility capacity is 6 and the census was 5 during today’s visit. Residents were observed in their bedroom and in the living room during the visit.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had all the requirements and were in compliance with regulation guidelines. In the resident bathrooms, hot water temperatures were measured in both bathrooms. In bathroom #1 hot water measured at 143.7 degrees Fahrenheit, and in bathroom #2 hot water measured at 139.2 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms.

Smoke detectors were observed in resident rooms, the hallway, and living room. The smoke detector in resident room # 1 was not working. All other smoke detectors were operational. One carbon monoxide detector was observed in the hallway near bathroom #1. A fully charged fire extinguisher was mounted on the wall in the kitchen.

In the kitchen LPA Haley observed a perishable and nonperishable food supply in compliance with regulation guidelines. Knives and sharp objects are kept locked in a cabinet above the sink. Resident medication, resident files and staff files were locked in a cabinet near the stove. Some hazardous cleaning materials were kept locked in the cabinet above the washer and dryer. The stove was clean and all burners on the stover were non operational. The burners on the stove needed to be lit with a lighter to ignite the flame on the stove. Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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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Document Has Been Signed on 02/20/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the stove was not in good repair. The burners on the stove needed to be lit with a lighter to light the flame on the burners. Based on observation the smoke detector in resident room #1 was not in good working order. , the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	The licensee will get the stove repaired and replace the smoke detector in the residents room. Confirmation the stove and smoke detector was repaired will be sent to LPA Haley by 1:00PM February 22, 2024.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of the hot water reaching temperatures above regulation requirements in both resident bathrooms, the licensee did not comply with the section cited above, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	The licensee will adjust the hot water temperatures to comply with regulation guidelines. Confirmation the hot water temperature was adjusted will be email to LPA Haley by 1:00PM February 22, 2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of a ripped window screen in resident room #3, the licensee did not comply with the section cited above which poses a potential health and safety rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	The licensee will have the screen replaced or repaired by 1:00PM February 23, 2024. Licensee will email LPA Haley a photo of the replaced screen by the POC due date.

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of the printer in the dining room, the printer in not in good repair and copies of requested documents (resident roster and LIC500) could not be provided during the visit.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	The licensee with have the printer in the kitchen repaired or removed by 1:00PM February 23, 2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of an old bed frame and old mattress in the back yard that need to be disposed of, the licensee did not comply with the section cited above which poses potential safety risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	The licensee will have the items removed by 1:00PM February 23, 2024. The licensee will email LPA Haley a photo once the clutter debris have been removed.

Type B

Section Cited

CCR

87219(a)

Planned Activities

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not comply with the section cited above which poses a personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	The licensee will incorporate additional activities for the residents by 1:00PM February 23, 2024. The licensee will email LPA Haley a list of the new activities to be incorporated in the community and a plan to ensure the residents all have the opportunity to participate in activities.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELYA SENIOR HOME	FACILITY NUMBER: 306004712
	VISIT DATE: 02/20/2024

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In the hallway, right across from the main bathroom, LPA Haley observed a locked desk with resident medications. In the locked desk/cabinet next to the locked medication desk, there is a locked cabinet with staff and resident files. There was a fully charged fire extinguisher hanging on the wall next to the locked staff and resident files. Down the hallway near the second resident bathroom, a supply of clean linen was observed. Across from bathroom #2, a carbon monoxide detector was observed and right below a fully charged fire extinguisher was mounted on the wall.

The garage was used to store a few facility items that are still in good repair. A supply of nonperishable food items was observed in the garage. The cabinet being used to store the nonperishable food items was missing a cabinet door and a red curtain/sheet was being used to cover the missing cabinet door. Photos were taken.

The back yard had a shaded patio area with a table and chairs. There was a shed in the back yard that’s used for storage of additional facility items. The back yard was free of tripping hazards clutter and debris.

Emergency evacuation drills are conducted quarterly and the first evacuation drill for 2024 has not been scheduled yet.

Licensee/Administrator Elizabeth Mullins was consulted on the importance of keeping the facility organized. Administrator Mullins has a lot of supplies and was instructed to keep everything organized and to go through everything and dispose of things not needed to prevent clutter.

Deficiencies are being cited as a result of today’s visit.

An exit interview conducted and a copy of this report, and appeal rights were provided to Imelda Martinez.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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