Adelya Senior Home Iii

Maintain facility in clean, safe, sanitary condition

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.

Provide resident hot water for personal care

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.

Call 9-1-1 for imminent health threats

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.

Care and supervision as defined by statute and rules

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.

Document required significant condition changes

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.

Maintain facility in clean, safe, sanitary condition

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 visitorsThis 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.

Licensee responsibility for records confidentiality

87506(c)(1) Resident RecordsThe 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.

Based on review of the centrally stored medication form & MAR, the licensee did not comply with the section cited above infive 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.

Perform physical examination with diagnosis and exam results

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.

Maintain facility in clean, safe, sanitary condition

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.

Maintain equipment and dishware in good repair

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.

Maintain facility in clean, safe, sanitary condition

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.

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.