306004779-11-16-2023-22-AS-MSTC-CXT4S7-20231121182103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004779
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:18:22 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/08/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231108125250

FACILITY NAME:	ADELYA SENIOR HOME III		FACILITY NUMBER:	306004779
ADMINISTRATOR:	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:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Maricel Lindsy - Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility failed to get resident medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received against this facility on November 8, 2023. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Director Maricel Lindsy was contacted via telephone and arrived shortly after and was present for the remainder of the visit.

Regarding the allegation: Facility failed to get resident medical attention in a timely manner.

Interviews with Director Lindsy, facility staff, Residents 1 (R1) son-in-law, and R1’s physician revealed R1 received the appropriate medical attention after an unwitnessed fall. The day of the fall, staff contacted Director Lindsy and Angels Hospice. Director Lindsy contacted R1’s son-in-law regarding the unwitnessed fall. During an interview with R1 son-in-law, he confirmed he was notified of the fall immediately. Angels Hospice confirmed they came to assess the resident after the fall, and a doctor came to Xray R1’s hip which revealed a fracture.
Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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-20231108125250

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 306004779
	VISIT DATE: 11/16/2023

NARRATIVE

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Interviews with Director Lindsy, R1’s Physician, Hospice, and R1’s son-in-law, confirm R1’s family decided the resident would not be sent out and would not receive surgery for the fracture.

Based on the information gathered during the investigation through interviews, the allegation mentioned above is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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