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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320075
Report Date: 11/18/2021
Date Signed: 11/18/2021 08:05:20 PM

Document Has Been Signed on 11/18/2021 08:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ADAMS HOUSE, INC., THEFACILITY NUMBER:
198320075
ADMINISTRATOR:ADAMS, TERRENFACILITY TYPE:
735
ADDRESS:806 E.CLAUDE STREETTELEPHONE:
(310) 756-6654
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 0DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Terren AdamsTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Terren Adams, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 4 Ambulatory developmentally disabled clients (age 18-59).

There are currently no clients at this time awaiting for approval form South Central Regional Center clients in placement. The facility is a two-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, family room/dining room, kitchen/tv room, living room, indoor and outdoor activity area, laundry room and an attached garage.



LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured in bathrooms 130 F and 172 F. Administrator will have corrected before clients. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected, and administrator will have 7 days of non-perishable and there was enough perishable food. 2 Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

LIC 809-C is on the next Page

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ADAMS HOUSE, INC., THE
FACILITY NUMBER: 198320075
VISIT DATE: 11/18/2021
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors station ( Located in common areas and restrooms). LPA observed were wearing face coverings and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Terren Adams, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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