ADELYA SENIOR HOME II

Official classification

Type A

Official code

87465(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 of 4 residents having OTC and PRN medications without a physicians order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2026 Plan of Correction Licensee stated they will discontinue use of medications until they have a physicians order and sent a statement of understanding to LPA by POC due date.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 4 of 4 residents having bed rails with no physicians orders which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2026 Plan of Correction Licensee removed all bedrails from the beds and stated they will not be put back until the physicians orders are obtained. Licensee to send LPA a statement of understanding to LPA by POC due date.

Official classification

Type B

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in LPA not observing a carbon monoxide detector in the facility. Which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2026 Plan of Correction Licensee stated they will obtain a carbon monoxide detector and send proof 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: Based on observation and interview, a strong urine odor was observed in one out of the five residents bedrooms and one staff corroborated that the urine smell is coming from the commode, which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee stated there will be a deep of resident's bedroom, will replace commode and will submit prood of CCLD/LPA via email by POC due date.

Deadline recorded: Mar 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in thre out of five resident records, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee stated that the Physician's Bed Rail orders will be obtained and will submit proof to LPA via email by POC due date.

Official classification

Type B

Official code

87705(b)(1)(A)

Regulation authority

CCR

What the official deficiency says

(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (A) Dementia care, including, but not limited to, knowledge about hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, licensee did not ensure current training was completed in three out of three staff, which poses a potential Health, Safety, and Personal Rights risk to persons with Dementia in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee stated that annual training and CPR certifications will be completed and submitted to LPA via email by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited by completing a current Needs & Services Plan in five out of the five resident records, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee stated they will review and complete all resident Needs & Service Plans and submit proof to LPA via email by POC due date.

Official classification

Type B

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 a potential health and safety risk to persons in care. Based on Resident medication and record review, the licensee failed to update/document five resident records of centrally stored prescription medications for each resident and MARs.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee will ensure all resident MARs contain a record of centrally stored medications for all residents in care and sign off on each medication administered, effective immediately. Licensee stated they will review regulations and re-train the facility staff on how to accurately record resident medications. Licensee stated they will email LPA the content covered in the training, training attendees and the date and time of training and email to CCLD by POC due date.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not ensure three out of three showers had non-slip mats, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee stated they will install non-slip mats and submit proof to LPA by POC due date. Licensee purchased mats and placed in all showers during visit.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 observation, the licensee did not comply with the section cited above in three out of three bathrooms, which poses an immediate health and safety risk to persons in care. LPA observed the water temperature measure between 132.6 to 138.2 degrees F.

Official plan of correction

POC Due Date: 07/04/2025 Plan of Correction Licensee made adjustments to hot water during visit and temperature measured properly when tested a second time. Licensee stated they will keep temperature logs for resident bathroom every two hours for the next 24 hours and submit records to CCLD via email by 5pm on 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 LPA observation, 2 out of 4 stove burners are not operational without an external ignitor and kitchen refrigerator is in need of repairs. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction Licensee stated he will have stove and refrigerator repaired by POC due date and submit proof to CCLD via email by POC due date.

Official classification

Type B

Official code

1569.895(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, facility has 2 cases of emergency water available for 5 residents and 2 staff members and a 2-day supply of perishable food in garage. There was no non-perishable emergency food supply available at the time of the visit. This poses a potential health and safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction Licensee will purchase enough emergency water and food supply for 5 residents and 2 staff members and submit proof to CCLD via email by POC due date.