Inspection Reports for Adelya Senior Home III

Licensing Program Analyst Rose Ruppert made an unannounced case management visit to amend a deficiency page from a visit on September 25, 2025.

The Plan of Correction cited for a Basic Services in-service with staff was completed, and the LIC9099 deficiency page was amended and re-signed.

An unannounced case management visit was made to amend a deficiency page from a prior visit on September 25, 2025, to verify completion of Plans of Correction related to staff in-services and documentation.

The Plan of Corrections cited on the deficiency page were completed, including staff in-services for 9-1-1 protocols and documentation for change of condition/re-appraisals. An audit of resident files confirmed all required licensing forms were completed.

An unannounced complaint investigation was conducted due to an allegation that a resident sustained an unexplained injury while in care due to lack of care and supervision.

The investigation substantiated that Resident #1 had an unwitnessed fall during the night and was not checked on until the next morning, resulting in delayed medical attention and serious injuries. The facility lacked awake night staff and failed to provide adequate supervision despite knowing the resident was a fall risk.

The complaint was substantiated. Resident #1 sustained an unexplained injury due to lack of care and supervision. The facility was cited under Title 22, Division 6 of the California Code of Regulations. A civil penalty is pending determination.

The inspection was an unannounced visit conducted for the purpose of completing a Case Management Deficiency related to a complaint investigation (control number 22-AS-20250414124920).

The facility was found deficient for failing to immediately call 911 after a resident's unwitnessed fall, resulting in a 52-minute delay in medical attention, and for not documenting significant changes in the resident's behavior and fall risk during reappraisal despite knowledge of the resident's wandering behavior, which led to a fall and hospitalization.

Investigation was conducted for complaint control number 22-AS-20250414124920. The complaint involved a resident's unwitnessed fall and inadequate supervision and documentation by the facility. The deficiencies were substantiated as the facility failed to ensure resident safety and proper documentation.

An unannounced complaint investigation was conducted in response to allegations that staff did not provide access to a resident's record and did not properly sanitize the facility.

The investigation substantiated that staff denied the Ombudsman access to Resident 1's medical records despite written consent, and that the facility had a strong urine odor, particularly in Resident 2's room, indicating inadequate sanitation and maintenance.

The complaint was substantiated. Staff denied the Ombudsman access to Resident 1's medical records despite written consent and verbal confirmation from the resident. Staff also failed to properly sanitize the facility, with a strong urine odor observed, especially in Resident 2's room.

The inspection was an unannounced required 1-Year annual visit using the CARE Inspection Tool to evaluate compliance with licensing requirements.

The facility was found to have unsanitary conditions in the kitchen and bathroom, clutter and toxin storage issues in the garage, and an exit gate in need of repair. Additionally, there were incomplete medical assessments and medication administration records not properly documented for all residents.

Licensing Program Analyst Jerome Haley conducted an unannounced visit to the facility to complete the required Annual inspection.

The facility was inspected for compliance with regulations including structure, kitchen, medications, resident and staff files, and safety equipment. Citations were issued for deficiencies related to the stove and maintenance issues such as a damaged screen door and cleanliness concerns in the kitchen and bathrooms.

An unannounced visit was conducted to investigate a complaint alleging the facility failed to get resident medical attention in a timely manner.

Interviews with the director, staff, resident's son-in-law, and physician confirmed the resident received appropriate medical attention after an unwitnessed fall. The allegation was deemed unfounded as the resident's family decided against sending the resident out for surgery.

The complaint alleged the facility failed to get resident medical attention in a timely manner. The investigation found the allegation to be unfounded based on interviews and evidence.

An unannounced complaint investigation visit was conducted following a complaint received on 11/08/2023 regarding the facility's failure to report a resident's fall and injury.

The investigation substantiated that the facility failed to report Resident 1's unwitnessed fall and injury to the Regional Office. Interviews and document reviews confirmed the fall occurred on October 18, 2023, and no incident report was submitted as required by regulations.

The complaint alleged the facility failed to report a resident’s fall and injury. The allegation was substantiated based on interviews with the Director, staff, Resident 1's son-in-law, physician, hospice provider, and document review.

An unannounced complaint investigation visit was conducted in response to allegations that a resident sustained a pressure injury while in care and that the facility refused medical services for the resident.

The investigation found that Resident #1 developed a Stage 1 pressure injury and received home health and wound care services as ordered. The allegations were unsubstantiated due to lack of preponderance of evidence that the injury was caused by neglect or refusal of medical services by the facility.

The complaint was unsubstantiated. Although the allegations may have happened or are valid, there was not sufficient evidence to prove neglect or refusal of medical services by the facility.