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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 08/08/2023
Date Signed: 08/08/2023 12:32:10 PM


Document Has Been Signed on 08/08/2023 12:32 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:
08/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Thomas AdamsTIME COMPLETED:
12:50 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced case management visit in conjunction with complaint visit 22-AS-20230731160550. LPA was granted entry by staff. LPA identified themselves and discussed purpose of the visit with Caregiver Tony Alejan. Administrator Thomas Adams arrived during the visit.

Upon conducting a complaint investigation visit, while touring facility LPA observed Medication closet was unsecure and had no lock. Resident 1 has diagnosis of Alzheimer's dementia.

During tour, staff informed LPA, one upstairs bedroom is occupied by a renter (RT1). Renter does not show as cleared for background check in Guardian. RT1 was not present during visit.

During visit LPA issued a technical Advisory regarding Regulations of Continuation Of License Under Emergency conditions and transferability of license. Administrator was handed a copy of regulation requirements.


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 were left at the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/08/2023 12:32 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: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2023
Section Cited
CCR
87705

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87705(f)(2) Care of persons with Dementia. (f)The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Licensee secured medications during the visit. Licensee to fix medication closet, send photo and notify Department of update by 8/15/23.
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This requirement is not being met as evidenced by Based on observation Licensee failed to ensure medications were inaccesible to residents with dementia.This poses an immediate health and safety risk to residents in care.
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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: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/08/2023 12:32 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: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2023
Section Cited
CCR
87355(e)(1)(f)

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All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. (f) Violation result immediate civil penalties of ($100) per day max 5 days
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Licensee to obtain criminal record clearance for renter and forward proof of fingerprints processed to LPA by POC due date.
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This requirement is not being met as evidenced by based on observation and interview, Licensee failed to ensure Renter 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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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: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3