198320075-9-20-2024-11-AS-PSCT-D9AMV9-20240920095622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320075
Report Date: 09/20/2024
Date Signed: 09/20/2024 09:56:29 AM

Document Has Been Signed on 09/20/2024 09:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ADAMS HOUSE, INC., THE		FACILITY NUMBER:	198320075
ADMINISTRATOR/ DIRECTOR:	ADAMS, TERREN		FACILITY TYPE:	735
ADDRESS:	806 E.CLAUDE STREET		TELEPHONE:	(310) 756-6654
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 0	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Terren Adams		TIME VISIT/ INSPECTION COMPLETED:	10:00 AM

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On 9/20/24, at 9:00am, Licensing Program Analyst (LPA) Perry Scott made an unannounced inspection to Adams House, Inc., The. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was met by Terren Adams, Administrator, and the purpose of the visit was explained. The facility is licensed to serve four (4) developmentally disabled clients (age 18-59) of which four (4) may be ambulatory. Currently, the home has (0) clients. The facilities’ annual fees are due on 11/10/24 for $1,170.00. This includes past due fees and annual fees that were not paid. To avoid late fees/forfeiture of your license, the balance must be paid by this date. Forfeiture will require you to submit a new licensing application and fees before operating any facility requiring a license. In the event of forfeiture, the Department will notify all appropriate referral agencies and remove the name of your facility from our list of licensed facilities.

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 conducted a records review of (0) client record, (0) staff records, (0) clients Personal & Incidental Records and reviewed the facility disaster plan. The facility does have any staff or clients currently. Therefore, no records were available to review. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

At 09:20am, LPA and Terren Adams, toured the physical plant. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. The water temperature was incompliance with Title 22 regulations. A comfortable temperature is maintained in the facility.

Report continued on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ADAMS HOUSE, INC., THE	FACILITY NUMBER: 198320075
	VISIT DATE: 09/20/2024

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LPA observed the facility to be clean and storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available. The fire extinguishers were charged, and smoke/ carbon monoxide detectors were operable.

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

LPA did not observe any deficiencies; therefore, no citations were issued at this time.

An exit interview was conducted, and a copy of the report was given to Terren Adams, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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