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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003003
Report Date: 08/26/2024
Date Signed: 08/26/2024 03:31:48 PM


Document Has Been Signed on 08/26/2024 03:31 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:THOMAS ADAMSFACILITY TYPE:
740
ADDRESS:418 SHOSHONI AVENUETELEPHONE:
(714) 996-2139
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 3DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Alfredo "Freddy" GambolTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Freddie Gambol and explained the purpose of the inspection.

During the inspection, LPA and Staff Gambol conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with three resident bedrooms, one staff bedroom, two bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 106.5-107.9 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication cabinet was observed to be locked; however, medication is being pre-poured into a plastic weekly medication organizer for each resident; a Deficiency was cited on this date.

Administrator (AD) Thomas Adams arrived at 2:30 p.m. to assist with the inspection. LPA reviewed three resident files and three staff files. One of three resident files did not have an appraisal dated or signed in the last twelve months; a Deficiency was cited on today’s date. Staff files did not contain any documentation for staff training conducted in the past year and a copy of staff training conducted was unavailable for review; a Deficiency was cited on today’s date. LPA interviewed residents and staff.

Based on the observations made during today’s inspection, 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: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
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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Document Has Been Signed on 08/26/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, SHOSHONI
FACILITY NUMBER: 306003003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and AD interview, the licensee did not comply with the section cited above as a copy of liability insurance is not currently being maintained, which poses a potential personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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AD stated liability insurance will be obtained and copy provided to LPA via email by POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in two of two staff records, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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AD stated staff training will be conducted to meet annual training requirement and provide LPA with proof via email 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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, SHOSHONI
FACILITY NUMBER: 306003003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above in three of three resident medication which poses a potential health and safety risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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AD stated medication will no longer be tranferred between containers and staff training will be condcuted regarding storage of medication and proof provided to LPA via email by POC date.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 in two of three resident records, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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AD stated pre-admission appraisals will be conducted moving forward. AD stated they will provide LPA with a written plan of action indicating how they will ensure compliance of regulation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/26/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, SHOSHONI
FACILITY NUMBER: 306003003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

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 in one of three resident records which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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AD stated resident appraisal will be completed and updated, and copy provided to LPA via email by POC date.
Section Cited
Other Provisions
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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4