<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003003
Report Date: 06/24/2022
Date Signed: 06/24/2022 10:17:23 AM


Document Has Been Signed on 06/24/2022 10:17 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 HOME, SHOSHONIFACILITY NUMBER:
306003003
ADMINISTRATOR:NANCY ADAMSFACILITY TYPE:
740
ADDRESS:418 SHOSHONI AVENUETELEPHONE:
(714) 996-2139
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 3DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Alfredo GamboaTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by staff Alfredo Gamboa and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA Gutierrez and staff Gamboa conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a single-story house with four bedrooms, and two bathrooms, with one bedroom occupied by staff. During the inspection LPA observed one staff and three residents in care. Residents were observed resting in their respective rooms and in the living room area. A 2-day supply of perishable and a 7-day supply of non-perishable foods was observed during today’s visit. Upon record review LPA noted emergency care requirements were met. LPA observed the facility does not have a 30-day supply of PPE on hand; a Technical Advisory was given on this date.

LPA reviewed and confirmed facility policies and practices regarding resident screening; a Technical Advisory was given on this date, staff screening, visitation, COVID-19 surveillance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the 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 was 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: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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 1