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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004779
Report Date: 05/17/2022
Date Signed: 05/18/2022 07:52:10 AM


Document Has Been Signed on 05/18/2022 07:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 IIIFACILITY NUMBER:
306004779
ADMINISTRATOR:MARICEL LINDSEYFACILITY TYPE:
740
ADDRESS:6533 VIA ESTRADATELEPHONE:
(714) 202-5075
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maricel and Larry LindseyTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Licensee's Larry and Maricel Lindsey. Residents present were napping in their rooms and two were watching tv in the living room. LPA toured the facility with Maricel Lindsey and the following was observed:

Covid signs were posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. The Administrator for this facility is Maricel Lindsey and her Administrator Certificate expired on 2/3/22. She is awaiting her new certificate. Larry Lindsey's certificate expires 12/25/23. Resident bedrooms met regulation guidelines. Bathrooms contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. Smoke and carbon monoxide detectors were operational and fire extinguishers were present. LPA observed an outside visitation area with ample shading. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured closet for resident medication and files.

During the visit, LPA observed staff wearing a masks. LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of masks and frequent hand washing for staff. Administrator is reminded to review Department PINS and to keep updated on Department Requirements regarding Infection Control, Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Larry Lindsey.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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