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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000567
Report Date: 12/01/2023
Date Signed: 12/01/2023 10:08:05 AM


Document Has Been Signed on 12/01/2023 10:08 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: 1DATE:
12/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Antonio "Tony" AlejanTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of meeting with Licensee Nancy Adams. LPA met with Staff 1 (S1) Tony Alejan and explained the reason for the visit. S1 stated Licensee was away in Louisiana and had not seen her since late September. S1 stated they can reach her by text and phone.

Licensee was contacted by phone and spoke with LPA. Per Licensee, she continues operating the facility and uses it as her primary residence. Licensee stated she is only on vacation visiting her daughter in Louisiana and anticipates she will be returning on Tuesday, 12/05/23. Licensee stated that Staff 2 (S2) Thomas “Tommy” Adams is acting Administrator in her absence. LPA reminded Licensee a Designation of Responsibility (LIC308) form must be completed and submitted to Community Care Licensing (CCL) regional office in order to designate responsibility to another staff in her absence and a new application (LIC200) must be submitted to CCL in the event of a change of ownership. Licensee stated she understood.

Based on observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023
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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