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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 12/20/2023
Date Signed: 12/20/2023 10:55:30 AM


Document Has Been Signed on 12/20/2023 10:55 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
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: 0DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Antonio "Tony" AlejanTIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of meeting with Licensee Nancy Adams. LPA met with Staff Tony Alejan and explained the reason for the visit. Staff Alejan stated Licensee was not present at the moment and had last seen her on 12/09/23 after she returned from Louisiana. Per Staff Alejan, Licensee is involved in day to day operations and he coordinates with her and Thomas "Tom/Tommy" Adams, who is currently acting as Administrator (AD). Staff Alejan provided LPA with a copy of Designation of Responsibility (LiC308) signed by both Tom and Nancy Adams. Tom Adams has a current AD certificate with an expiration date of 2/17/25.

LPA and Staff Alejan conducted a tour of the facility. Facility currently has a zero census and LPA did not observe any residents in care. LPA observed facility bedroom upstairs to be locked; per Staff Alejan, a tenant is residing in the facility. LPA conducted a review of Guardian roster and confirm tenant is not eligible for background clearance. Facility did not ensure tenant had background clearance prior to residing in a licensed facility. LPA also observed 6 out of the 7 bedroom smoke detectors were missing or tested inoperable.

Based on observations made during today's inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations; immediate civil penalties are also being assessed. See the attached LIC421BG. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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Document Has Been Signed on 12/20/2023 10:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306000567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
87355(e)(1)(f)(1)

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(e) All individuals subject to a criminal record review... shall prior to... residing... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption...(f)(1) Subsequent violations ... will result in a civil penalty.,. ($100) per violation per day.. maximum of (30) days.
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AD stated they have already served 30-day eviction notice and are currently working on obtain unlawful detainer for uncleared individual. AD will provide LPA with a copy of unlawful detainer notice once obtained for uncleared individual.
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This requirement is not met as evidence by;
Staff admitted a tenant is residing in the facility. Per Guardian roster, tenant is not eligible for background clearance. Facility did not ensure tenant had background clearance prior to reside in the facility which poses an immidiate safety risk to persons in care.
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Type A
12/21/2023
Section Cited
CCR87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not being met as evidenced by:
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LIcensee will install smoke directors prior to accepting any resident into care and will provide LPA with video proof of fire detectors installed and operating.
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LPA observed 6 out of 7 bedroom smoke detectors were missing or tested inoperable. This poses an immediate health and safety risk to persons in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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