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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 10/03/2022
Date Signed: 10/03/2022 10:07:25 AM


Document Has Been Signed on 10/03/2022 10:07 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: 5DATE:
10/03/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nancy AdamsTIME COMPLETED:
10:20 AM
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On today’s date, Licensing Program Analyst (LPA) LPA Edward Tapia conducted a Case Management visit regarding complaint # 22-AS-202206220 94709 with the purpose to conduct an interview with Resident 1 (R1) regarding an allegations listed on complaint.

At about 9:30 am LPA Tapia was granted entry to the facility. Administrator was made aware of the purpose of this visit. LPA conducted an interview with Resident 1 (R1).

An exit interview was conducted with the Administrator and copy of this report was provided and left at the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
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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