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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:59:58 PM

Document Has Been Signed on 01/23/2024 02:59 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, 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:
01/23/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Antonio "Tony" AlejanTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection for the purpose of following-up on deficiencies cited on 12/20/23. LPA met with Staff Tony Alejan and explained the reason for the visit.

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 six out of seven smoke detectors downstairs continue to be missing or tested inoperable. At approximately 2:20 p.m., LPA spoke with Administrator designee (ADD) Thomas Adams by phone. Per ADD, smoke detectors will be replaced immediately and prior to admitting residents. ADD also stated they would provide LPA with copies of required documentation to be formally designated as Administrator via email by Close of Business (COB) 1/23/24.

Based on observations made during today's visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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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Document Has Been Signed on 01/23/2024 02:59 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 01/23/2024 at 02:45 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADAMS FAMILY HOME
FACILITY NUMBER: 306000567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2024
Section Cited

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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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LPA observed six out of seven smoke detectors downstairs 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 Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
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