Adelya Senior Home III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced required annual inspection using the CARE Inspection Tool. Upon arrival at the facility, LPA Haddadin was greeted and granted entry by Caregiver (CG) Connie Martinez. The facility is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility also has a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood and consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a living area, dining area, kitchen, attached garage, and an outdoor covered patio area. At the time of the visit, there were five (5) residents in care. During the inspection, LPA toured the interior and exterior areas of the facility. All bathrooms were observed to be clean, sanitary, and operational. Hot water was tested and measured between 103.9 degrees Fahrenheit and 104.2 degrees Fahrenheit and a deficiency was cited for the hot water. The kitchen was observed to be clean and organized, with an adequate food supply, including at least a two-day supply of perishable food and a seven-day supply of non-perishable food. Knives and cleaning supplies were secured in a locked kitchen cabinet and were inaccessible to residents. All kitchen appliances were observed to be operational and in working condition. The fire extinguishers were observed to be fully charged, with the most recent purchase date recorded as May 20, 2026. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The first aid kit contained the required supplies. Medication was observed to be locked and secured in a cabinet located in the hallway. Facility records did not show documentation of any emergency drills being conducted. LPA inspected the garage and observed that it was being used for storage. One vehicle was parked inside the garage, and bed frames and other boxes were stored around the vehicle. The garage was filled with storage items, and boxes were stacked approximately halfway around the vehicle, which prevented LPA from fully accessing areas of the garage. The condition of the garage was observed to be unsafe, unclean, and a potential fire hazard; a deficiency was cited per title 22. Residents’ bedrooms were inspected and contained the required furnishings. The backyard included a covered patio with a seating area. No bodies of water were observed. The exit gate was operational, and no hazards or obstructions were observed in the backyard. A review of resident files revealed no discrepancies. Staff files were also reviewed and found to be complete, with the required documentation maintained in each file. Based on observations made during the inspection, deficiencies are being cited pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to Caregiver Connie Martinez at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Jun 10, 2026

Allegation investigated: -Neglect / Lack of adequate care from staff resulted in resident sustaining multiple pressure injuries. -Staff providing care beyond the scope of the license (wound care). -Staff did not provide resident linens. -Staff did not ensure resident's toileting needs were met. -Staff did not ensure resident was provided daily activities.

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry to the facility by Larry Lindsey, Licensee and LPA stated the purpose of the visit. An initial investigation visit was conducted on June 30, 2025. During the visit, LPA Vanegas conducted a tour of the facility, and observed all residents, resting in their respective rooms and the common areas of the facility. LPA Vanegas gathered and reviewed pertinent records pertaining to residents in care in regard to the allegations stated above. LPA Vanegas interviewed one resident as four different residents were not available for interview. Furthermore, LPA Vanegas interviewed the administrator, and three different staff members. Continued on LIC9099-C Unsubstantiated It is alleged that neglect / Lack of adequate care from staff resulted in resident sustaining multiple pressure injuries, specifically to feet, ankle, buttocks, hip and back. Record review revealed that resident (R1) had an order summary report at Town & Country SNF on May 24, 2022, with the following: rehab and evaluation for treatment are as follows, heel protector of heel, (TX) of coccyx, left groin, right groin, skin, bilateral heel, discoloration of bilateral lower extremities, and upper extremities as of 5/13/22. R1 was admitted to the facility on June 7, 2022. Functional capabilities assessment reflects reposition from side to side. Admissions records for Providence Home Health dated May 18, 2024, admissions diagnoses are pressure ulcer of left ankle stage 2, pressure ulcer of left heel unstageable, kidney disease, atrial fibrillation, thrombophilia, dysphagia, vascular disease, atherosclerosis of aorta, degenerative disease of nervous system, anxiety, and personal history of other diseases of circular system. Interviews with 2 of 2 staff stated that R1 had closed wounds and staff would apply ointment and/or bandages to them. Interviews conducted revealed that staff 2 of 2 stated that R1 did not have the wounds prior to entering the facility. Staff 4 of 4 stated that residents are rotated every two hours. Interview with residents stated that they are unaware of residents getting rotated because they don’t go into that resident’s room. Staff treat residents with dignity and respect. It is alleged that staff providing care beyond the scope of the license revealed the following. No dates or times were provided of when the alleged violation took place. It was reported that staff on duty provide wound care for R1’s pressure injuries sustained while under the supervision of the facility. Interviews with 4 of 4 staff did not corroborate the allegation. All staff stated that they provided sanitation of the wound if needed by applying ointment and bandages. R1 was admitted to home health and they provided wound care. Interview with resident stated that they have never witnessed any wound care treatment being performed on any resident. It is alleged that staff did not provide resident linens. It was reported that staff on duty denied a linen for R1 due to R1 getting the linens dirty too frequently. Interviews with 4 of 4 staff did not corroborate the allegation, it was stated that if a resident requires changing or cleaning, they provide that service right away. Interview with resident revealed the following, if clean linens are needed, they will receive them right away. Continued on LIC9099-C It is alleged that staff did not ensure that the residents’ toileting needs were met. It was stated that resident was observed to be soiled on several occasions, and they were changed only when it was brought to the staff’s attention. Interviews with 4 of 4 staff revealed that they change residents whenever it is observed that they have a soiled diaper. Interview with resident revealed that they have never witnessed any residents sitting in a soiled diaper. It is alleged that staff did not ensure resident was provided daily activities, specifically to staff leaving R1 in their room with no stimulation such as the television being on. Interviews with 4 of 4 staff revealed that the facility offers activities, however the residents do not like to take part in the activities. Interview with resident revealed the following that the facility does offer activities, however they do not like to participate in many activities. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 22-AS-20250627101345

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced case management visit to amend a deficiency page from a visit on September 25, 2025. LPA was greeted and granted entry and explained the purpose of the visit. LPA met with Maricel Lindsey, Administrator. LPA spoke with Licensee, Larry Lindsey via phone, regarding the purpose of the visit and that the LIC9099 deficiency page would be amended and re-signed. LPA acknowledged the Plan of Correction (POC) cited for a Basic Services in-service with staff was completed. An exit interview was conducted with Maricel Lindsey, Administrator, and a copy of this report and the amended LIC 9099-D was left at the facility.the state’s words, verbatim · CDSS document, Oct 13, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced case management visit to amend a deficiency page from a visit on September 25, 2025. LPA was greeted and granted entry and explained the purpose of the visit. LPA met with Maricel Lindsey, Administrator. LPA also spoke with Licensee, Larry Lindsey via phone, regarding the purpose of the visit and that the deficiency page would be amended and re-signed. LPA acknowledged the Plan of Corrections (POC) cited on the deficiency page were completed. The POCs for staff in-services for 9-1-1 protocols and documentation for change of condition/ re-appraisals were emailed to LPA by POC date. LPA spoke with Administrator to audit current resident files to make sure all licensing forms, such as Appraisals/ Needs and Services Plans or any Re-Appraisals were completed. An exit interview was conducted with Maricel Lindsey, Administrator, and a copy of this report and the amended LIC 809-D was left at the facility.the state’s words, verbatim · CDSS document, Oct 7, 2025

Allegation investigated: Resident sustained unexplained injury while in care due to lack of care and supervision

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit. It was alleged resident sustained unexplained injury while in care due to lack of care and supervision. During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed medical records from the University of California Irvine (UCI) Medical Center. The investigation revealed the following: Resident #1 (R1) was admitted to the facility on April 4, 2025. Per Physician report dated March 25, 2025, R1 had a diagnosis of Dementia. Physician report further assessed R1 had motor impairment/ paralysis, confused and disoriented and was non-ambulatory. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) On May 13, 2025, Resident #1 (R1) had an unwitnessed ground level fall. It is unknown what time of night this fall occurred. Two of two Staff interviewed stated R1 was put to bed between 8pm and 9pm and was not checked on until the next morning. Per interviews with two of two staff & Licensee, the facility does not have awake staff at night. At 8:15am on May 14, 2025, Staff #1 (S1) and Staff #2 (S2) found R1 on the floor with a cut above R1’s left brow. Staff picked R1 up from the ground and placed R1 in a wheelchair. Staff then proceeded to clean the bedroom of the blood on the floor. After cleaning the room, staff contacted the Licensee Lawrence Lindsey, who then called 911. Hospital records obtained show Paramedics were dispatched at 9:02am and arrived on scene at 9:07am. Due to S1 and S2 not immediately calling 9-1-1 there was an approximate 52 minute delay in R1 receiving medical attention. Paramedics reported that upon arrival, R1’s room was cleaned of blood but the resident was covered in dried blood on their hair, face and body. R1 was transferred to UCI Medical Center after paramedics observed a hematoma with 2 cm laceration to the head; and scattered bruising in various signs of healing on R1. Per medical records obtained, R1 was diagnosed with a closed fracture to a right rib; subdural hematoma; intraventricular hemorrhage; impaired mobility; and dementia. Per R1’s family, R1 has had a history of recurrent falls since December 2024 and correlating with Urinary Tract Infections (UTIs). Family informed Licensee that R1 wandered at night and had been working with R1’s Primary Care Physician to manage insomnia with medications. During interview with Licensee, Licensee acknowledged knowing R1 had a tendency to wander at night and was a fall risk. Despite, knowing R1’s wander behavior, no additional staff was provided to ensure R1’s safety while wandering. When asked about fall prevention methods, Licensee stated a fall mat had not been implemented due to R1’s family not providing one and was unaware if bedrails had been ordered for R1. Licensee reported they were unaware if R1 had a pendant to call for help. R1 was discharged to a Hospice Facility where they passed away on April 29, 2025. Per Death Certificate, R1’s cause of death is listed as traumatic intraventricular hemorrhage. Based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegation that the Resident sustained unexplained injury while in care due to lack of care and supervision is substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e) An exit interview was conducted with Maricel Lindsey, Administrator, and a copy of this report, 9099-D, LIC421IM, LIC811 Confidential Names, and Appeal Rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 22-AS-20250414124920

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 26, 2025

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.the state’s words, verbatim · CDSS document, Sep 25, 2025

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.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit for the purpose of completing a Case Management Deficiency. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit. During the investigation for complaint control number 22-AS-20250414124920, the following deficiencies were observed. On May 13, 2025, Resident #1 (R1) had an unwitnessed ground level fall. It is unknown what time of night this fall occurred. Two of two Staff interviewed stated R1 was put to bed between 8pm and 9pm and was not checked on until the next morning. Per interviews with two of two staff & Licensee, the facility does not have awake staff at night. At 8:15am on May 14, 2025, Staff 1 (S1) and Staff 2 (S2) found R1 on the floor with a cut above R1’s left brow. Staff picked R1 up from the ground and placed R1 in a wheelchair. Staff then proceeded to clean the bedroom of the blood on the floor. Staff contacted the Licensee Lawrence Lindsey, who then called 911. Hospital records obtained show Paramedics were dispatched at 9:02am and arrived on scene at 9:07am. Due to S1 and S2 not immediately calling 9-1-1 there was an approximate 52 minute delay in R1 receiving medical attention. Per R1’s family, R1 has had a history of recurrent falls since December 2024 and correlating with Urinary Tract Infections (UTIs). Family informed Licensee that R1 wandered at night and had been working with R1’s Primary Care Physician to manage insomnia with medications. During interview with Licensee, Licensee acknowledged knowing R1 had a tendency to wander at night and was a fall risk. Despite, knowing R1’s wander behavior, no additional staff was provided to ensure R1’s safety while wandering. When asked about fall prevention methods, Licensee stated a fall mat had not been implemented due to R1’s family not providing one and was unaware if bedrails had been ordered for R1. (Continued on LIC 809-C) (Continued from LIC 809) Licensee reported he was unaware if R1 had a pendant to call for help. Per pre-appraisal dated March 10, 2025, R1 did not require observation at night and was not documented as a known fall risk. Facility conducted a reappraisal on April 4, 2025, and documented R1 did not need special observation/night supervision due to confusion, forgetfulness, and wandering, despite having knowledge that R1 was exhibiting wander behavior at night. At no point did the facility update R1’s appraisal to document R1’s new behaviors and implement a plan to meet R1’s needs. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Larry and Maricel Lindsey, Administrator, and a copy of this report, 809-D, LIC811 Confidential Names List and Appeal Rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 26, 2025

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.the state’s words, verbatim · CDSS document, Sep 25, 2025

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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(b) · Plan of correction due date: Sep 26, 2025

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.the state’s words, verbatim · CDSS document, Sep 25, 2025

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.

Allegation investigated: Staff did not provide access to a resident's record Staff did not properly sanitize the facility

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to conduct an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. It was alleged staff did not provide access to a resident's record and staff did not properly sanitize the facility. During the investigation, LPA conducted interviews with staff and residents in care and reviewed records obtained. The investigation determined as follows: Regarding the allegation staff did not provide access to a resident's record, it was reported the facility did not allow the visiting Ombudsman access to Resident 1 (R1)'s medical record even though the Ombudsman had obtained written consent from R1 on June 30, 2025. LPA interview with R1 stated they provided consent to the Ombudsman. LPA showed a copy of the signed consent form to R1 and R1 confirmed they signed the consent form. Continued on 9099-C dated 07/11/2025 Substantiated R1 stated Ombudsman wanted to review their medical information due to a discussion had between R1 and the Ombudsman on June 30, 2025. R1 stated they later rescinded the consent verbally over the phone with the Ombudsman hours after the Ombudsman left the facility. LPA interviews with two out of two staff interviewed stated during the visit on June 30, 2025, the Ombudsman asked to view R1's medical records. Two out of two staff stated they declined to provide medical records to the Ombudsman even with R1's written consent. One out of two staff added they told the Ombudsman they needed consent from R1's family member in order to provide R1's records. Ombudsman along with Staff 1 (S1) called the Department's duty line to discuss the matter and spoke with LPAs Garlli Tat and Kevin Saborit-Guasch during the Ombudsman visit at the facilty. Both on duty LPAs explained to S1 that in the absence of a conservatorship, R1 could agree to share their personal information with the Ombudsman as part of their duties at the facility. S1 acknowledged that after the phone call with the on duty LPAs, S1 still declined to share R1's medical record with the Ombudsman while the Ombudsman was at the facility. The Ombudsman never obtained R1's medical records. LPA record review of R1's file did not indicate a conservatorship nor any power of attorney documents in place. Regarding the allegation staff did not properly sanitize the facility, it was reported there is a strong urine odor at the facility. LPA Arias observed a lingering urine odor coming from the living room. LPA observed a very strong urine odor coming from Resident 2 (R2)'s room. LPA interview with staff 2 (S2) stated R2 is not cognitive and urinates on different places in the room including on the wood floor. R2 has to be redirected to use the bathroom. LPA observed some of the wood flooring has warped in R2's room. S2 stated they mop the floor often but that does not remove the urine odor. Based on LPA interviews, observations, and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 22-AS-20250706214148

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Jul 25, 2025

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.the state’s words, verbatim · CDSS document, Jul 11, 2025

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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 8, 2025

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.the state’s words, verbatim · CDSS document, Jul 11, 2025

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.

Type of visit: Required - 1 Year

On June 16, 2025, at 1:00pm, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Connie Martinez after explaining the purpose of the visit. Administrator Lawrence Lindsey was contacted by telephone and stated he was available by phone, as needed. AD Lawrence Lindsey has an administrator certificate with an expiration date of December 25, 2025. The facility is licensed to operate for six (6) non-ambulatory, of which one (1) may be bedridden and a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, an attached garage, and outside covered patio area. There are five residents on census, all present during today’s visit. LPA obtained copies of pertinent documents, including facility records, clients/staff rosters and Personnel Record (LIC500). During the visit, LPA Bentley toured the interior and exterior of the physical plant with CG Martinez and observed the facility to be appropriately furnished at the time of visit. Sharp objects were stored and locked. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available. 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. CONTINUE TO LIC 809-C PAGE... Emergency safety drills were last conducted on March 1, 2025 and are completed on a quarterly basis. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were tested and observed operational. The facility has one (1) fire extinguisher that is fully charged in the kitchen, with a last service date of March 30, 2025. Liability Insurance is effective July 1, 2024 through July 1, 2025. Interviews were conducted with four (4) residents and two (2) staff during today’s visit. Medication and Medication Administration Record (MAR) reviewed. Based on medication and record review, the licensee did not document medication administered to all residents since 6/6/2025. LPA Bentley conducted an audit of five (5) resident files (R1-R5) and three (3) staff files (S1-S3). Resident #1 has an incomplete Physican's Report with primary diagnosis missing from page 2 and date next to Physician's signature. Based on today’s observations, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA spoke with Administrator Lawrence Lindsey by phone, an exit interview was conducted and a copy of this report, and LIC809-D was provided to Caregiver Connie Martinez.the state’s words, verbatim · CDSS document, Jun 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit to the facility to complete the required Annual inspection. LPA Haley met with Licensee/Administrator Larry Lindsey and toured the facility. The facility has a capacity of 6, of which 6 can be non-ambulatory and 1 may be bedridden. The facility phone number 714.202.5075. Structure: The facility is one level structure with six bedrooms. Currently five bedrooms are being occupied by residents and 1 bedroom is being occupied by staff. Kitchen: Sharps locked in a cabinet near the stove. A perishable food supply was observed in the refrigerator and freezer. Non-perishable food supply was observed in the cabinets. Stove/Appliances: There’s one stove with 4 burners and a warmer, a refrigerator, dishwasher, washer, and dryer. The top left burner, the warmer and the bottom right burner on the stove would not light unassisted. Toxins: All cleaning supplies and chemicals are locked in the garage. Medications, First-Aid Kit: Resident medications are locked in a closet near the front door. There’s a first aid kit in the kitchen. Resident & Staff Files: Resident and staff records are kept in a cabinet behind the dining room table. Bedrooms: Resident bedrooms were in compliance with regulation guidelines. Bathrooms: The bathrooms have working toilets, wash basin and shower. Grab bars were tightly secured to the walsl. Hot Water: Hot water was measured in the range of 115.8 – 119.1 degrees F. Continued on LIC809C Hygiene Supplies: The facility has an adequate supply of hygiene items available. Linens, Hygiene, Emergency Supplies: Additional linens for each resident are stored in a hallway closet. Emergency Evacuation Drills: The most recent evacuation drill was conducted March 1, 2024. Medication Review: There are currently five residents in the facility and medication was reviewed for all five residents. Resident File Review: A file review was completed for all five residents. Staff File Review: 3 staff files were reviewed during the visit. Garage: Walkways were free of obstruction. A washer and dryer was observed. A refrigerator and an additional supply of non-perishable items were observed Backyard: Clean, organized and walkways are free of obstruction. There's a table and chairs under a shaded patio area, and another table with a sunshade and chairs. Smoke Detectors/Carbon Monoxide Detectors: Smoke detectors and the carbon monoxide detector tested operational. There’s a fully charged fire extinguisher on the counter behind the dining table. Misc (P&I): N/A. The facility does not manage any of the resident’s money. Activities, Recreation, Reading Material, etc: Puzzles, word search, exercise balls, clay the residents use. Citation(s): Citations will be issued for violations observed during the inspection. After the citation was written for the stove and dishwasher in disrepair, it was discovered the dishwasher is in good working condition. The outlet that the dishwasher was plugged into was not providing power to the dishwasher. The stove still needs to be repaired or replaced. Exit Interview: Exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Larry Lindsey.the state’s words, verbatim · CDSS document, Jun 19, 2024

Allegation investigated: Facility failed to report resident’s fall and injury.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received 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 report resident’s fall and injury. During an interview with Director Lindsy it was confirmed no incident report was sent to the Region Office regarding Resident 1's fall and injury. Interviews with Director Lindsy, facility staff, Resident 1's son-in-law, R1's physician, and hospice provider confirmed R1 had an unwitnessed fall and sustained an injury to the hip. A review of Angels Hospice RN/LVN Communication Flow Sheet revealed R1 fell on October 18, 2023. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6. An exit interview was conducted and a copy of this report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 22-AS-20231108125250

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 22, 2023

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.the state’s words, verbatim · CDSS document, Nov 16, 2023

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.

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

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 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.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 22-AS-20231108125250