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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 01/31/2024
Date Signed: 01/31/2024 09:46:19 AM


Document Has Been Signed on 01/31/2024 09:46 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:THOMAS ADAMSFACILITY TYPE:
740
ADDRESS:16171 CAIRO CIRCLETELEPHONE:
(714) 501-5398
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 0DATE:
01/31/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Antonio "Tony" AlejanTIME COMPLETED:
10:00 AM
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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 and 1/23/24. 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 all smoke detectors downstairs have been installed. Smoke detectors were all tested individually and observed to be operable. The second story of the facility consists of three bedrooms. LPA observed one out of three bedrooms to be occupied by staff, and two out of three bedrooms are currently unoccupied. Per Staff Alejan, previous uncleared tenant moved out on 1/28/24. LPA confirmed both bedrooms were free of any personal belongings. Two out of two deficiencies previously cited have been corrected and are now cleared.

Based on observations made during today's visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report 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: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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