306004712-2-3-2025-22-AS-EKIM-DDJVKV-20250203153058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004712
Report Date: 02/03/2025
Date Signed: 02/03/2025 03:31:05 PM

Document Has Been Signed on 02/03/2025 03:31 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ADELYA SENIOR HOME		FACILITY NUMBER:	306004712
ADMINISTRATOR/ DIRECTOR:	LAWRENCE LINDSEY		FACILITY TYPE:	740
ADDRESS:	16912 SAGA DRIVE		TELEPHONE:	(657) 444-9567
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	02/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Caregiver- Imelda Martinez		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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On February 3, 2025, at 9:10am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Imelda Martinez. LPA Kim spoke with Licensee (LI) Lawrence Lindsey over the phone and explained the purpose of the visit. LI Lindsey said they could not attend today’s visit and CG Martinez can sign on their behalf for the report.

The facility is licensed to operate for six (6) nonambulatory residents and has a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: one (1) staff bedroom, four (4) resident bedrooms, two (2) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with CG Ferdinand Baquiran. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 111.8 degrees F to 114.4 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly.

Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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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Document Has Been Signed on 02/03/2025 03:31 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELYA SENIOR HOME	FACILITY NUMBER: 306004712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.319(a)

Regulations

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed the facility did not have internet access device such as a computer, smart phone, tablet, or other device that is dedicated to the residents. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	Licensee states they will purchase an internet access device that is dedicated for resident use and provide proof to CCLD via email to edward.kim@dss.ca.gov by POC due date 2/17/2025.

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of four residents. LPA observed in resident 4 (R4) had full bed rails with no hospice record for full rails. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	Licensee states they will provide the hospice order and care plan for the full bed rails for Resident 4 (R4) to CCLD via email to edward.kim@dss.ca.gov by POC due date 2/17/2025.

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

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELYA SENIOR HOME	FACILITY NUMBER: 306004712
	VISIT DATE: 02/03/2025

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (657-444-9507) remains available. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and mounted next to the kitchen.

LPA Kim conducted an audit of resident files (R1-R4), staff files (S1-S4), and medication and medication administration record. LPA Kim conducted two (2) staff interviews and one (1) resident interviews.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed the following deficiencies: 1) The facility did not provide an internet access device that is dedicated for resident use and 2) Resident 4 (R4) has a full bed rail without a hospice care plan and hospice order. Technical violation was issued at the time of the visit.

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

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC809 (FAS) - (06/04)

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