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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 06/14/2024
Date Signed: 06/14/2024 09:42:09 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/14/2024 09:42 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/
DIRECTOR:		THOMAS ADAMSFACILITY TYPE:
740
ADDRESS:16171 CAIRO CIRCLETELEPHONE:
(714) 501-5398
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 0DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Nicolas DiozonTIME VISIT/
INSPECTION COMPLETED:
09:50 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of conducting a Required – 1 Year Inspection. LPA met with Contractor Nicolas Diozon and discussed the purpose of the inspection.

LPA and Contractor Diozon toured the facility and observed the following: there are extensive renovations taking place at the facility. There are no residents or staff. There is no furniture or food. The water, gas, and electricity are currently running. An estimate of when renovations will be completed is unknown. At 8:51 a.m. LPA placed a call to Licensee Nancy Adams and left a voicemail requesting a call back. At 8:57 a.m. LPA placed a call to Administrator (AD) Thomas Adams and left a voicemail requesting a call back.

Contractor Diozon informed LPA that he believed a change of ownership had taken place. At 9:28 a.m. LPA placed an additional call to Licensee Nancy Adams and left a detailed message regarding facility license being non-transferable and change of ownership requirements.

There are no immediate health and safety concerns, as the facility has a census of zero and is completely unoccupied at this time.

Based on the observations made during today’s inspection, 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 provided at the end of the inspection.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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