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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200311
Report Date: 10/04/2022
Date Signed: 10/19/2022 02:50:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2022 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20220908091925
FACILITY NAME:THOMAS-ADAMS RESIDENTIAL CARE FACILITY, INC.FACILITY NUMBER:
019200311
ADMINISTRATOR:HAROLD THOMASFACILITY TYPE:
735
ADDRESS:5152-5158 FOOTHILL BLVD.TELEPHONE:
(510) 533-3470
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:32CENSUS: 30DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Rosita Stavens, House ManagerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not safeguard resident's personal items.
Facility's toilet is in disrepair.
Facility's door is in disrepair.
Facility's heater is in disrepair.
Resident's do not smoke in designated areas.
Facility is not free of pests.
Facility is not following COVID-19 protocols.
INVESTIGATION FINDINGS:
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***Amended report ***On 10/19/2022 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver an amended report for the complaint investigation in regards to the allegations above. LPA met with Rosita Stevens, House Manager and informed her the reason for the visit.

During the course of the investigation LPA toured the facility and found the toilets were operational, doors locked properly, heater was operational and there were no signs of pests. Three smoking areas were observed with facility residents smoking in them. There was no smell of cigarette smoke in any other part of the facility.

LPA observed numerous signs and posters related to COVID ie: stop the spread, signs and symptoms, hand washing and cough etiquette. Administrator reported that the facility staff takes the temperature of the residents twice daily; morning and night and maintains documentation.

***amended report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20220908091925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: THOMAS-ADAMS RESIDENTIAL CARE FACILITY, INC.
FACILITY NUMBER: 019200311
VISIT DATE: 10/04/2022
NARRATIVE
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***Amended Report continues from LIC9099***

Also during the course of the investigation LPA interviewed Facility Administrator regarding the safeguarding of residents personal items. Facility Administrator reported that residents are responsible for their own possessions. Some residents have lock boxes in their rooms.

Based on LPA's observations and interviews which were conducted the allegations were found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is UNSUBSTANTIATED.

Exit interview conducted, a copy of this reported provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2