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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:04:11 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ADAMS FAMILY HOMEFACILITY NUMBER:
306000567
ADMINISTRATOR:NANCY ADAMSFACILITY TYPE:
740
ADDRESS:16171 CAIRO CIRCLETELEPHONE:
(714) 501-5398
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 4DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Nancy AdamsTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Administrator Nancy Adams and explained the purpose of the visit.

During the visit LPA toured the facility with Nancy Adams. LPA observed Covid signage at front entrance of facility as well as a sanitization station. Facility has required Department postings. LPA observed a copy of Administrator Certificate for Nancy Adams that expires . LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained ample supplies. Hand sanitizer, soap, wipes, gloves were present. LPA observed outside visitation area with ample shading. Residents were observed watching tv in the family room. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff at all times.

No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Nancy Adams.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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