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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002916
Report Date: 01/26/2026
Date Signed: 01/26/2026 04:55:44 PM

Document Has Been Signed on 01/26/2026 04:55 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:ARC FACILITY AT CAMINO 2FACILITY NUMBER:
306002916
ADMINISTRATOR/
DIRECTOR:		MICHAEL ADAMSFACILITY TYPE:
740
ADDRESS:2209 CAMINO DEL SOLTELEPHONE:
(714) 870-5830
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 4DATE:
01/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Caregiver Taisia SclifosTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On January 26, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Michael Adams was notified via telephone but was unable to assist with today's inspection. LPA observed that Michael Adams does not have a valid Administrator certificate on file, and that there is no pending application at this time.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for two. The facility is a single-story home with three resident bedrooms, two of which are shared, one staff room, two resident bathrooms, a living room, a dining room, a kitchen, and an attached three car garage. LPA accompanied by a care giving staff conducted a tour of the interior portion of the facility. On today's visit, LPA observed four residents in care and two staff present. LPA observed residents relaxing in the living room and in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected all three resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA observed the staff bedroom is kept locked and inaccessible to residents in care. LPA inspected the two resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 116.3 and 119.6 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916
VISIT DATE: 01/26/2026
NARRATIVE
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LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed kitchen knives and sharps are stored in a locked kitchen cabinet. A fire extinguisher is located in the dining room and it was observed to be charged and up to date on service. LPA tested the individual smoke detectors and carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 1, 2025. The centrally stored medication is kept in a locked kitchen cabinet. LPA observed a First Aid kit stored in the closet by the resident hallway. The First Aid kit was observed to have all the required components. The door leading to the attached three car garage is kept locked and inaccessible to resident in care. LPA observed the three car garage is used for storage and for laundry. LPA observed chemical and toxins to be stored in the garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA, accompanied by a care giving staff, conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates of the facility are self-latching and can be opened in an evacuation. LPA observed a pool located in the backyard which is adequately fenced and kept locked for resident safety.

LPA reviewed all four resident files. LPA observed that there was no Medical Assessment on file for Resident #1 (R1). LPA observed that the Reappraisal on file for Resident #3 (R3) was outdated. LPA reviewed four residents’ medication and medication administration records. LPA reviewed two staff files. All staff are background cleared and associated to the facility.

LPA observed that the licensee, Adams Residential Care Facilities, LLC, is not active and was suspended on December 1, 2011. LPA also observed that the annual fees for the facility were not paid in 2024 or in 2025. The AD was advised that if the annual fee are not being paid, it may result in forfeiture of the license.

Based on today's observations, deficiencies are being cited on the attached LIC809-D pages. An exit interview was conducted via telephone with Administrator Michael Adams. A copy of the report and Appeal Rights were provided to an authorized facility representative.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/26/2026 04:55 PM - It Cannot Be Edited


Created By: Brandon Lopez On 01/26/2026 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87205(b)
Accountability of Licensee Governing Body
(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that the licensee, Adams Residential Care Facilities, LLC, is not active and was suspended on December 1, 2011.
POC Due Date: 01/27/2026
Plan of Correction
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The Administrator stated that they will submit a written plan on how they will address this deficiency. The Administrator agreed to provide the written plan to LPA via email or fax by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/26/2026 04:55 PM - It Cannot Be Edited


Created By: Brandon Lopez On 01/26/2026 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that there was no Medical Assessment on file for Resident #1 (R1).
POC Due Date: 02/23/2026
Plan of Correction
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The Administrator stated that he will obtain a Medical Asessment for R1. The Adminstrator agreed to provide LPA the Medical Assessment for R1 via email or fax by POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that the most recent Reappraisal on file for Resident #3 (R3) was completed on 11/03/24.
POC Due Date: 02/23/2026
Plan of Correction
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The Administrator stated that he will complete a new Reappraisal for R3. The Administrator agreed to provide the Reappraisal to R3 to LPA via email or fax by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/26/2026 04:55 PM - It Cannot Be Edited


Created By: Brandon Lopez On 01/26/2026 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(g)
(g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that the Administrator listed on file, Michael Adams, does not have a valid Administrator certificate on file, and that there is no pending application at this time.
POC Due Date: 02/23/2026
Plan of Correction
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The Administrator stated that he will complete a written plan on how he will submit a renewal application to the Administrator Certification Bureau. The Administrator stated that he will provide the written plan to LPA via email or fax by POC date.
Type B
Section Cited
CCR
87156(a)
(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA also observed that the annual fees for the facility were not paid in 2024 or in 2025.
POC Due Date: 02/23/2026
Plan of Correction
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The Administrator stated that he will pay the balance for the facility's annual fees. The Administrator agreed to provide LPA proof of payment for the annual fees via email or fax by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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