306004762-3-16-2026-22-AS-APAO-DTA5DH-20260418195157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004762
Report Date: 03/16/2026
Date Signed: 03/16/2026 01:23:36 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
03/10/2026 and conducted by Evaluator Eboni Bentley

COMPLAINT CONTROL NUMBER: 22-AS-20260310175337

FACILITY NAME:	ADELYA SENIOR HOME II		FACILITY NUMBER:	306004762
ADMINISTRATOR:	LAWRENCE LINDSEY		FACILITY TYPE:	740
ADDRESS:	16419 VERNON STREET		TELEPHONE:	(657) 218-4680
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 4	DATE:	03/16/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Jimmy Estrella - Cargiver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff kicked resident.

INVESTIGATION FINDINGS:

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On March 16, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting an initial complaint investigation and deliver findings for the above allegation. LPA was greeted, introduced self, and was granted entry after stating the purpose of the visit to staff. Administrator Larry Lindsay was contacted via telephone, LPA stated the purpose of the visit, and Administrator granted permission for Caregiver Jimmy Estrella to sign the report.

During the course of the investigation, LPA reviewed and obtained copies of facility documents including: Resident Roster, Staff Roster, Resident Emergency Info & Contact Sheets, Physician's Reports, Personal Rights, and Needs and Services Plan for Resident #1 (R1). Interviews were successfully conducted with three residents, one staff, and two witnesses.

CONTINUE TO LIC9099-C.....

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026

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-20260310175337

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 II	FACILITY NUMBER: 306004762
	VISIT DATE: 03/16/2026

NARRATIVE

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Regarding the allegation, staff kicked resident, it is alleged that an altercation occurred between a resident and staff. It was reported that Resident 1 (R1) kicked Staff 1 (S1) and S1 kicked R1 back. Based on record review of admission agreement, R1 was admitted to the facility on September 3, 2025. The Physician’s Report for R1, dated September 3, 2005, states R1 was diagnosed with a brain tumor, stoke, has memory loss, and expresses frustration with the inability to do things on their own.

Five out of seven individuals interviewed denied the allegation. During interviews conducted, Witness 1 (W1) and Witness 2 (W2) stated staff are always nice to residents and respond promptly. W1 & W2 stated they have never observed staff being physically or verbally abusive to any residents in care. Two out of three residents interviewed denied the allegation, stating staff take good care of them and are always nice. One resident stated they are frustrated with not being able to do things they are used to doing, including getting out of bed and walking around the facility. All staff interviewed denied the allegation, stating R1 often gets upset and forgets how incidents occurred due to diagnosis. S1 stated R1 sometimes gets verbally and physically aggressive, however S1 denies ever kicking R1, stating they take a breaks whenever necessary but do not react to R1’s behavior. During an interview with R1, the resident admitted getting facts mixed up when recalling how previous incidents occurred. R1 stated they often move around the bed to get comfortable and sometimes prop their legs up against the bed rails. R1 stated they may have hit their leg on the bed rail but is not always clear about how things occurred.

Based on observations made, interviews that were conducted, and records reviewed, this Department did not find sufficient evidence to support the above allegation Staff kicked resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with staff and a copy of the report provided at exit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026

LIC9099 (FAS) - (06/04)

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