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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005904
Report Date: 01/13/2021
Date Signed: 01/14/2021 10:16:55 AM

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 HOMESFACILITY NUMBER:
306005904
ADMINISTRATOR:ADAMS, THOMASFACILITY TYPE:
740
ADDRESS:922 DIAMOND ROADTELEPHONE:
(714) 702-0605
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 0DATE:
01/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Thomas AdamsTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Michelle Reed contacted the facility via telephone to commence an announced Prelicensing visit due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call with Thomas Adams. Mr. Adams will be the designated Administrator for the facility. An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 9/21/2020 for a capacity of 6 non-ambulatory residents. The Placentia Orange County Fire Department conducted a Fire Safety Inspection on 5/7/2020 and granted a fire clearance for 6 ambulatory residents. The fire clearance will need to be changed to show approval for 6 non-ambulatory residents. A virtual tour of the physical plant was conducted inside and out at approximately 2:00pm with Thomas Adams and the following was observed:
Structure:
Facility is a one story house with 5 bedrooms and 2 bathrooms. Bedrooms #1, #3 and #5 are designated as resident rooms and bedroom #1 and #2 will be for staff. The resident bathroom will be bathroom #2. Applicant understands that if there are any changes to the current room designations, he must complete a new sketch and notify the Department. There is also a living room, family room and kitchen.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
The resident bedrooms accommodate residents' furnishings and meet Title 22 regulation at this time.
Bathrooms:
Bathrooms have a working toilets, sinks and showers. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Ombudsman poster was posted at the time of visit as well as the See Something, Say Something Poster for Complaints.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2021
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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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 HOMES
FACILITY NUMBER: 306005904
VISIT DATE: 01/13/2021
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Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables are stored in the kitchen and pantry and will include fruits and vegetables.
Smoke and Carbon Monoxide Detectors:
Smoke detectors and a carbon monoxide detector were present and in working order
Fire Extinguishers:
Fire extinguishers were present and charged but not mounted for easy access. Applicant was advised to mount at least one of the extinguishers.
Appliances:
Refrigerator/freezer and microwave were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Will be locked and inaccessible to residents
Water Temperature:
Tested and met Title 22 regulation at the time of visit, between 105 and 120 degrees F.
Medications, First Aid Kit & Manual:
First Aid kit present and stored with resident medications. Medications will be stored and locked in the facility living area.
Resident and Staff Files:
Records will be locked for privacy
Component III
Component III was conducted

The Pre-licensing is complete at this time. Pending a revised fire clearance, no corrections are needed.

The Licensee will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted with Thomas Adams and a copy of this report was emailed for signature.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
LIC809 (FAS) - (06/04)
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