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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000567
Report Date: 11/27/2023
Date Signed: 11/27/2023 04:27:56 PM

Unsubstantiated


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
11/22/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231122113715
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: 1DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Antonio AlejanTIME COMPLETED:
03:14 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to supervise residents by leaving them unattended.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Staff and explained the reason for the visit. The facility is a 2 story home with 7 bedrooms, living room, dining room, kitchen, office, storage room connected to the master bedroom, family room, 2 car garage and 3 bathrooms. 3 bedrooms are upstairs and there is a fireplace in the dining room. LPA and staff toured the facility. LPA interviewed witnesses.The investigation revealed the following. It was alleged that the staff left the facility on 11/19/2023 and left the residents unattended. Witnesses interviewed could not corroborate the report. Staff 1 reported they never left the residents unattended and have never left the facility without another staff member staying at the facility to watch the residents. There is no evidence to verify the allegation. Based on the information gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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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