306000567-7-8-2022-22-AS-MVAO-CHSSBR-20220830134419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000567
Report Date: 07/08/2022
Date Signed: 07/08/2022 12:46:35 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2020 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200914132703

FACILITY NAME:	ADAMS FAMILY HOME		FACILITY NUMBER:	306000567
ADMINISTRATOR:	NANCY ADAMS		FACILITY TYPE:	740
ADDRESS:	16171 CAIRO CIRCLE		TELEPHONE:	(714) 996-2139
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 5	DATE:	07/08/2022
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Nancy Adams		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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9

Staff makes inappropriate comments to resident

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Michelle Reed met with Administrator Nancy Adams to discuss the complaint findings for the above allegation. The investigation consisted of interviews with Administrator, staff, residents and witnesses as well as documentation from the facility. The following was determined:

Resident #1(R1) moved into the facility on 11/7/19 and moved out on 8/29/20. R1 needed assistance with all activities of daily living and medication management. R1 was non-ambulatory with mild cognitive impairment due to a stroke. Interviews were conducted with staff and two of five residents who were able to communicate. Interviews disclosed that Staff #1(S1) liked to joke with residents to make them laugh. S1 admitted to LPA that he did joke about cooking the facility dogs for dinner.
Based upon interviews and the review of records, the preponderance of evidence has been met and the allegation is substantiated.

See LIC9099D for cited deficiencies.An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee/Administrator Nancy Adams.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200914132703

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/11/2022 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights-Residents in all residential care facilities for the elderly shall be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to train all staff on personal rights of residents and provide proof to Licensing via certification by 7/11/22. S1 No longer works at the facility
	8 9 10 11 12 13 14	S1 admitted to LPA that as a joke, he told Residents that he cooked the facility dogs for dinner. This poses a potential personal rights risk to residents in care especially to residents that have cognitive impairment and may not see this as a joke.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2020 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20200914132703

FACILITY NAME:	ADAMS FAMILY HOME		FACILITY NUMBER:	306000567
ADMINISTRATOR:	NANCY ADAMS		FACILITY TYPE:	740
ADDRESS:	16171 CAIRO CIRCLE		TELEPHONE:	(714) 996-2139
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS:	DATE:	07/08/2022
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Nancy Adams		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff roughly handles resident
Staff shows residents inappropriate pictures from cell phone

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michelle Reed met with Administrator Nancy Adams to discuss the complaint findings for the above allegations. The investigation consisted of interviews with Administrator, staff, residents and witnesses as well as documentation from the facility. The following was determined:

Interviews were conducted with staff and two of five residents who were able to communicate. Interviews disclosed that Staff #1(S1) liked to joke with the residents. S1 would show the residents pictures of family from Facebook. He admits he did show a picture of someone in a bikini and a picture of a cake shaped like a bathing suit but never any inappropriate pictures. During R1’s stay at the facility, R1 had some bleeding on her chin and S1 applied pressure to R1’s chin to stop the bleeding.

Based upon interviews, the allegations above are unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to
Administrator Nancy Adams.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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