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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:51:17 PM

Document Has Been Signed on 09/21/2023 02:51 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:
09/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Caregiver, Antonio AlejanTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit on this day to conduct a case management to follow up on plan of correction (POC) for citations issued during a previous inspections issued by the Department dated 08/08/2023 and 09/12/2023. LPA met with staff 1(S1). During today’s visit LPA witnessed the following:

On 8/8/23 during unannounced inspection LPA observed a uncleared renter’s belongings at facility. Based on observations 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 still pending Criminal Background Clearance. On 9/12/23 A civil penalty was assessed for $3400 for failure to correct POC due 8/9/2023. A CIVIL PENALTY WAS ASSESSED FOR $900 FOR A CONTINUATION OF A DAILY PENALTY ASSESSED FROM 8/10/23. A $100 daily civil penalty will continue to accrue until this deficiency is cleared.

On 9/12/23, during a unannounced inspection LPA observed additional renter residing at facility was also pending Criminal Background Clearance. A civil penalty and citation were issued for violating Title 22 regulations.

On todays date LPA observed Renter 1 and Renter 2 still have belongings and are still residing at facility. Based off observations LPA verified that POC provided does not meet requirements. Therefore the POC was not corrected by due date 9/13/23. A CIVIL PENALTY WAS ASSESSED FOR $800 FOR FAILURE TO CORRECT. A $100 daily civil penalty will continue to accrue until this deficiency is cleared.

An exit interview was conducted with staff member. A copy of this report and civil penalty assessment and appeal rights were provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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