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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 09/12/2023
Date Signed: 09/12/2023 12:52:11 PM


Document Has Been Signed on 09/12/2023 12:52 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
ORANGE COUNTY RO, 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: 2DATE:
09/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Administrator Tom AdamsTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 08/08/23 in conjunction with complaint 22-AS-20230731160550. LPA Tirre explained reason for visit, was greeted and granted entry by Staff 1 (S1). Administrator Tom Adams arrived during visit.

On 08/08/23 facility failed to ensure that medications were locked while having dementia residents in care. On 8/10/2023 Administrator Tom Adams provided proof by photo of fixed medication cabinet. Deficiency cited under Title 22 Regulation 87705(f)(2) Pertaining to Care of persons with Dementia has been cleared. For this visit LPA conducted tour and observed medication cabinet was fixed and has secure locks. Licensee has complied with the terms of POC.

On 08/08/23 facility failed to ensure all individuals are subject to a criminal record review prior to working, residing or volunteering in a licensed facility. Deficiency cited under Title 22 Regulation 87355 (e)(1)(f). Although Administrator provided proof of paperwork of Renter (RT1) obtaining fingerprints, RT1 is pending Criminal Background Clearance. During visit it was observed that an additional residing house guest (RT2) is also pending Criminal Background Clearance. For this visit LPA observed that Licensee has not complied with the terms of POC resulting in repeat violation.

Based on the observations made during today's visit, the following violations are being cited and civil penalty issued per California Code of Regulations Title 22.



An exit interview was conducted and a copy of this report along with appeal rights was provided and explained.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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 09/12/2023 12:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ADAMS FAMILY HOME
FACILITY NUMBER: 306000567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2023
Section Cited
CCR
87355(e)(1)(f)(1)

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All individuals subject to a criminal record review... shall prior to working, residing or volunteering in facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. (f) Violation result immediate civil penalties... (1) Subsequent violations within a twelve (12)
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Administrator will begin process of eviction of uncleared individuals. Administrator has resident files and medications locked in secure location with key only available to staff. Administrator will provide Licensing copy of eviction notices for uncleared individuals by POC date. Administrator to
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 month period will result in civil penalty of ($100) per violation per day for a max of thirty (30) days. This requirement is not being met as evidenced by observation & interview, Licensee failed to ensure Renters has criminal record clearance before residing in the facility. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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notify uncleared individuals to have no contact or provide care with residents in care. Administrator to provide letter. Administrator to provide Special Incident Reports if any issues arise.

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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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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