198320075-11-13-2025-11-AS-PSCT-DNDW2H-20251113155420

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320075
Report Date: 11/13/2025
Date Signed: 11/13/2025 03:54:29 PM

Document Has Been Signed on 11/13/2025 03:54 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
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:	11/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Terren Adams		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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On 11/13/25, at 2:30pm, Licensing Program Analyst (LPA) Perry Scott made an unannounced annual required inspection to Adams House, Inc., The. 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 were due on 11/10/25 for $1,166.00. 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. Partial payments will not avoid late fees. 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 building 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.

At 3:00pm, LPA and staff toured the facility. 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 was provided, and adequate storage for client’s 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. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries are accessible to clients. The water temperature measured 115.8F degrees, and a comfortable temperature is maintained in the facility.

Report Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 11/13/2025 03:54 PM - It Cannot Be Edited

Created By: Perry Scott On 11/13/2025 at 03:32 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ADAMS HOUSE, INC., THE	FACILITY NUMBER: 198320075
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(b)

Administrator Qualifications and Duties

(b) All adult residential facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above as there is no proof of active administrator certification or pending renewal, which poses/posed a potential health, safety or personal rights risk to persons in care. The administrator’s certificate expired on 02/17/2025.
	POC Due Date: 12/05/2025
	Plan of Correction
1 2 3 4	Licensee will submit a copy of his pending renewal application for an Administrator Certification to LPA Perry Scott by POC due date of 12/05/25 with proof of payment to email perry.scott@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:

	Perry Scott
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

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: 11/13/2025

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LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of visit. 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 for the clients. All food items were stored properly. Medication cabinet was centrally stored and properly locked, first aid kit was checked and fully stocked with manual. The fire extinguishers were charged, and the smoke/ carbon monoxide detectors were operable. The facilities administrator’s certificate expired on 02/17/2025 and does not have a pending renewal on file as of this inspection. LPA did not conduct a record review because the facility does not have any clients or staff. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

LPA advised the facility 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.

Deficiencies observed: Licensee administrator’s certificate expired on 02/17/2025 and has no pending application in the Administrator Certification Bureau (ACB).

Deficiencies were cited during this inspection visit.

Note: *Citations that are not cleared by the due date of 12/05/25 will have a $100 fine assessed per day for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.

An exit interview was conducted, and a copy of this Facility Evaluation Report was provided to Terren Adams, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

LIC809 (FAS) - (06/04)

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