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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004762
Report Date: 07/03/2025
Date Signed: 07/03/2025 08:42:49 PM

Document Has Been Signed on 07/03/2025 08:42 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 IIFACILITY NUMBER:
306004762
ADMINISTRATOR/
DIRECTOR:		LAWRENCE LINDSEYFACILITY TYPE:
740
ADDRESS:16419 VERNON STREETTELEPHONE:
(657) 218-4680
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
07/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Emelda Estrella, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On July 3, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Imelda Estrella. LPA 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 Estrella can sign for the report on their behalf.

The facility is licensed to operate for six (6) non-ambulatory, of which one (1) may be bedridden, with a hospice waiver for three (3) residents. The home consists of 5 resident bedrooms, 1 staff bedroom, 3 bathrooms, living room, dining room, and kitchen.

LPA Bentley toured inside and outside of the physical plant with CG Estrella. There were no bodies of water or obstructions on the premises. A comfortable temperature of 76 degrees F was maintained 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 bedrooms were inspected and contained all the required elements. Bathrooms were found to be clean and operational. The water temperature measured between 132.6 to 138.2 degrees F. A deficiency was cited for water temperatures in bathrooms used by residents in care.

CONTINUE TO LIC809-C PAGE..
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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 II
FACILITY NUMBER: 306004762
VISIT DATE: 07/03/2025
NARRATIVE
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LPA Bentley observed the facility to be sanitary and 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 available and maintained properly. Emergency safety drills was last conducted on June 15, 2025 and are conducted quarterly. First aid kit is maintained and contains all the necessary elements.

During the visit, LPA Bentley observed the smoke detectors and carbon monoxide detectors were operable. A working telephone (657-218-46-80) remains available. The facility has one (1) fire extinguisher that was charged, mounted in the hallway, with a purchase date of June 16, 2025. Liability Insurance is effective 7/1/2025 and expires on 7/1/2026. The facility does not have a sufficient amount of emergency food and emergency water stored in the garage. A deficiency was cited.

Licensee/Administrator Lawrence Lindsey has an administrator certificate that expires on December 25, 2025.

Based on observations, deficiencies are being cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, a copy of this report, LIC809D and appeal rights were provided to Caregiver Imelda Estrella. 
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/03/2025 08:42 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/03/2025 at 04:41 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELYA SENIOR HOME II
FACILITY NUMBER: 306004762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above in three out of three bathrooms, which poses an immediate health and safety risk to persons in care. LPA observed the water temperature measure between 132.6 to 138.2 degrees F.
POC Due Date: 07/04/2025
Plan of Correction
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Licensee made adjustments to hot water during visit and temperature measured properly when tested a second time. Licensee stated they will keep temperature logs for resident bathroom every two hours for the next 24 hours and submit records to CCLD via email by 5pm on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 08:42 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/03/2025 at 04:41 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELYA SENIOR HOME II
FACILITY NUMBER: 306004762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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
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Based on LPA observation, 2 out of 4 stove burners are not operational without an external ignitor and kitchen refrigerator is in need of repairs. This poses an immediate health and safety risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee stated he will have stove and refrigerator repaired by POC due date and submit proof to CCLD via email by POC due date.
Type B
Section Cited
HSC
1569.895(a)(2)
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, facility has 2 cases of emergency water available for 5 residents and 2 staff members and a 2-day supply of perishable food in garage. There was no non-perishable emergency food supply available at the time of the visit. This poses a potential health and safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee will purchase enough emergency water and food supply for 5 residents and 2 staff members and submit proof to CCLD via email by POC due date.
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
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
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