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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003003
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:44:41 PM


Document Has Been Signed on 01/24/2024 02:44 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
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:
01/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alfredo "Freddy" GambolTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced case management inspection for the purpose of determining Administrator (AD) status. LPA met with Staff Freddy Gambol and explained the reason for the visit.

At approximately 1:45 p.m., LPA spoke with Administrator designee (ADD) Thomas Adams by phone. Per ADD, they are acting AD and Licensee continues to be Nancy Adams. ADD stated they will provide LPA with copies of required documentation to be formally designated as Administrator via email by Close of Business (COB) 1/24/24. LPA informed ADD, that as AD they are required to maintain a personnel file for themselves, available to Community Care Licensing (CCL) upon request for review or to obtain copies. ADD stated they understood.

Based on observations made during today's visit, 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: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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