Adelya Senior Home Iii

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.

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.

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.

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.

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 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.

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.

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.

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.

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.