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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005344
Report Date: 09/20/2021
Date Signed: 09/23/2021 02:02:50 PM

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 HOMESFACILITY NUMBER:
306005344
ADMINISTRATOR:LINDSEY, MARICELFACILITY TYPE:
740
ADDRESS:495 S WESTRIDGE CIRCLETELEPHONE:
(657) 223-9886
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 5DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Larry LindseyTIME COMPLETED:
11:00 AM
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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 Staff Gene and Yen David. Licensee Larry Lindsey arrived shortly after LPA to conduct a family tour. The focus of the visit was Infection Control. LPA toured the facility with Yen David at approximately 10:15am 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. LPA toured resident rooms and bathrooms. Restrooms observed 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. LPA observed an outside visitation area with ample shading. Residents were watching tv, in their rooms resting as well as walking through the facility. Social distancing was observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication room for resident medication and files. All residents have at least a 30 day supply.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Licensee is reminded to review all Department PINS in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as Testing and Mask Guidelines. Staff should be also be trained on the 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: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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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