306004779-6-10-2026-22-AS-SHAN-DUWQKL-20260610121430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004779
Report Date: 06/10/2026
Date Signed: 06/10/2026 12:15:56 PM

Document Has Been Signed on 06/10/2026 12:15 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 III		FACILITY NUMBER:	306004779
ADMINISTRATOR/ DIRECTOR:	MARICEL LINDSEY		FACILITY TYPE:	740
ADDRESS:	6533 VIA ESTRADA		TELEPHONE:	(714) 202-5075
CITY:	ANAHEIM HILLS	STATE: CA	ZIP CODE:	92807
CAPACITY: 6		CENSUS: 5	DATE:	06/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:33 PM
MET WITH:	Connie Martinez		TIME VISIT/ INSPECTION COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced required annual inspection using the CARE Inspection Tool. Upon arrival at the facility, LPA Haddadin was greeted and granted entry by Caregiver (CG) Connie Martinez. The facility is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility also has a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood and consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a living area, dining area, kitchen, attached garage, and an outdoor covered patio area. At the time of the visit, there were five (5) residents in care. During the inspection, LPA toured the interior and exterior areas of the facility. All bathrooms were observed to be clean, sanitary, and operational. Hot water was tested and measured between 103.9 degrees Fahrenheit and 104.2 degrees Fahrenheit and a deficiency was cited for the hot water. The kitchen was observed to be clean and organized, with an adequate food supply, including at least a two-day supply of perishable food and a seven-day supply of non-perishable food. Knives and cleaning supplies were secured in a locked kitchen cabinet and were inaccessible to residents. All kitchen appliances were observed to be operational and in working condition. The fire extinguishers were observed to be fully charged, with the most recent purchase date recorded as May 20, 2026. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The first aid kit contained the required supplies. Medication was observed to be locked and secured in a cabinet located in the hallway.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

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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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 III	FACILITY NUMBER: 306004779
	VISIT DATE: 06/10/2026

NARRATIVE

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Facility records did not show documentation of any emergency drills being conducted.
LPA inspected the garage and observed that it was being used for storage. One vehicle was parked inside the garage, and bed frames and other boxes were stored around the vehicle. The garage was filled with storage items, and boxes were stacked approximately halfway around the vehicle, which prevented LPA from fully accessing areas of the garage. The condition of the garage was observed to be unsafe, unclean, and a potential fire hazard; a deficiency was cited per title 22.
Residents’ bedrooms were inspected and contained the required furnishings. The backyard included a covered patio with a seating area. No bodies of water were observed. The exit gate was operational, and no hazards or obstructions were observed in the backyard.
A review of resident files revealed no discrepancies. Staff files were also reviewed and found to be complete, with the required documentation maintained in each file.
Based on observations made during the inspection, deficiencies are being cited pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to Caregiver Connie Martinez at the conclusion of the inspection.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2026 12:15 PM - It Cannot Be Edited

Created By: Samer Haddadin On 06/10/2026 at 11:48 AM

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 III	FACILITY NUMBER: 306004779
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on the licensee did not comply with the section cited above, the garage was observed to be unsafe, unclean, and a potential fire hazard which poses an immediate health, safety risk to persons in care.
	POC Due Date: 06/12/2026
	Plan of Correction
1 2 3 4	Licensee to clean up the garage and make sure there is space for full inspection of the unit, and send proof to LPA by POC due date,

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(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 the licensee did not comply with the section cited aboveBased on observation, the licensee did not comply with the section cited above by not having hot water of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).which poses an immediate health and safety to persons in care.
	POC Due Date: 06/11/2026
	Plan of Correction
1 2 3 4	LPA to fix hot water and send proof to LPA 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.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC809 (FAS) - (06/04)

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