ADELYA SENIOR HOME III

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 06/12/2026 Plan of Correction 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,

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 06/11/2026 Plan of Correction LPA to fix hot water and send proof to LPA by POC due date

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: On May 13, 2025 R1 had a ground level fall and staff did not immediately call 911. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee and Administrator will review regulations pertaining to the deficiences and will conduct a staff inservice on 9-1-1 protocol. Licensee emailed LPA with in-service documentation, signed by staff, by POC date.

Deadline recorded: Sep 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals: (b)The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement was not met as evidenced by: Licensee did not document R1’s wander behavior or fall risk on reappraisal completed despite being aware of behavior. As a result, R1 sustained a fall resulting in hospitalization and fracture. This poses an immediate safety risk to residents in care.

Official plan of correction

Licensee and Administrator will review regulations pertaining to the deficiences and will conduct a staff inservice on re-assessment and re-appraisal documentation.. Licensee emailed LPA with in-service documentation signed by staff, by POC date.

Deadline recorded: Sep 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Staff placed R1 to bed between 8-9pm on May 12, 2025 and did not check on R1 until May 13, 2025 at 8:15am. This poses an immediate health and safety risk to residents in care. A civil penalty will be assessed.

Official plan of correction

Licensee and Administrator will review regulation pertaining to the deficiences cited and will conduct a staff inservice on Basic Services to be provided to residents in care. Licensee completed POC and emailed LPA with in-service documentation, signed by staff, by POC date.

Deadline recorded: Sep 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

87506(c)(1) Resident Records The licensee and all employees shall...make available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by: Based on LPA interviews and record review, the licensee did not comply with the section cited above for Resident 1 which posed a potential personal rights risk to persons in care.

Official plan of correction

Licensee stated he will provide a signed statement of understanding on regulation 87506(c)(1) and email LPA by POC due date.

Deadline recorded: Jul 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenanace shall include provision of maintenanace services and procedures for the safety and well-being of residents, employees and visitors This requirement is not met as evidenced by: Based on LPA interviews and observations, the licensee did not comply with the section cited above for Resident 2's room which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee stated they will contract a cleaning company to clean the flooring or replace flooring with tile and provide proof to LPA by POC due date.

Deadline recorded: Aug 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above in one out of five resident Physician's Reports. Resident #1 has an incomplete Physican's Report with primary diagnosis missing from page 2 and date next to Physician's signature.

Official plan of correction

POC Due Date: 06/30/2025 Plan of Correction Licensee will schedule visit with physician and resident to obtain complete report and email updated Physican's Report to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 Based on observation, the licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care. LPA observed unsanitary conditions in the kitchen and bathroom, the garage full of storage and clutter, and there is only one exit gate in the backyard, which is in need of repair. LPA also observed multiple areas in the garage where toxins are stored in the same area as food items.

Official plan of correction

POC Due Date: 06/30/2025 Plan of Correction Licensee will have the exit gate repaired or replaced, have a deep cleaning of the kitchen and all bathrooms, organize/remove clutter in garage, and remove all toxins from areas where food is stored. Licensee will email LPA Bentley photos of the repaired/replaced exit gate, cleaned kitchen, bathrooms and garage by POC due date.

Official classification

Type A

Official code

87465(h)(6)(A-F)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. Licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. This requirement is not met as evidenced by: Deficient Practice Statement Based on review of the centrally stored medication form & MAR, the licensee did not comply with the section cited above in five out of five resident records, which poses an immediate health and safety risk to persons in care. Based on medication and record review, the licensee did not document medication administered to all residents since 6/6/2025.

Official plan of correction

POC Due Date: 06/30/2025 Plan of Correction Licensee will ensure all resident MARs contain a record of each medication pas for all residents in care, effective immediately. Licensee will review regulations and re-train the facility staff on how to accurately record resident medications passes. Licensee will email LPA the content covered in the training, training attendees and the date and time of training aby POC due date.

Official classification

Type B

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements All equipment, fixed or mobile, and dishes, shall be kept clean and mainained in good repair and free of breaks, open seams, cracks, or chips. This requirement is not met as evidenced by: The stove and the dishwasher is in disrepair. The stove is missing knobs and two burners and the warmer will not light unassisted. Deficient Practice Statement Based on observation, and interview confirmation, the licensee did not comply with the section cited above in which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee Larry Lindsey agrees to have the stove and the dishwasher replaced or repaired and email receipts of the repairs or replacements to LPA Haley by the POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: The screendoor on the sliding door that leads to the back yard in in disrepair. There's a large hole near the handle. There's oil on the knobs directly above the stove in the kitchen. Several spiders and spider webs were observed in the bathroom near bedrooms. Photos were taken of the stove, spiders, spider webs, and screendoor. Deficient Practice Statement Based on observation and interview confirmation, the licensee did not comply with the section cited above, which poses a potential health and safety or risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Administrator Lindsey will have the screen door repaired or replaced, and agrees to have the kitchen and all bathrooms deep cleaned. Administrator will email LPA Haley of the repaired or replaced screen door, and photos of the bathroom and cabinets above the stove after the deep cleaning has been completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) a written report shall be submitted to the licensing agency... within seven days... (D) Any incident which threatens the welfare, safety, or health of any resident, such as... or unexplained absence of any resident. This requirement is not being met as evidenced by interview confirmation with Director Lindsy that an incident report was not completed and sent to the Regional Office. Multiple interviews and a review of a Hospice document titled " RN/LVN Communication Flow Sheet " reveal R1 had an unwitnessed fall and sustained an injury October 18, 2023.

Official plan of correction

Director Maricel Lindsy will review Regulation Section 87211 (Reporting Requirements) and email a plan of action that will prevent a failure to report in the future. The plan will include who will be responsible for sending incident reports to the Regional Office. POC due date: November 22, 2023 at 1:00 PM.

Deadline recorded: Nov 22, 2023. A deadline is not proof that correction was completed.