306005904-4-15-2022-22-AS-ETAA-CDHL9L-20220415083339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005904
Report Date: 04/14/2022
Date Signed: 04/15/2022 08:33:48 AM

Document Has Been Signed on 04/15/2022 08:33 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 HOMES		FACILITY NUMBER:	306005904
ADMINISTRATOR:	ADAMS, THOMAS		FACILITY TYPE:	740
ADDRESS:	922 DIAMOND ROAD		TELEPHONE:	(714) 702-0605
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 3	DATE:	04/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Blanca Guerrero, Tomas Adams		TIME COMPLETED:	06:35 PM

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 Analysts (LPAs) Edward Tapia, Celine De Perio made an unannounced required annual inspection in this facility. LPAs met with caregiver Blanca Guerrero and stated the purpose of this visit. AD Thomas Adams arrived during the visit at 1:45pm and provided assistance. The facility is a single level structure and licensed for six non-ambulatory of which 4 are ambulatory. This facility offers Residental Care of the Elderly. About 1:30 PM, LPAs Tapia, DePerio were granted entry. However, they were not asked to complete a the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPAs observed four clients in care and two staff members on the duty. Upon review of record 1 out 2 staff was not associated to the facility. A Civil Pentaty is being issued today for $100 due to background clearance of staff member 1 was not completed. LPAs toured the interior and exterior portions of the facility. LPA’s notice admin license was not posted by the front door of the facility. Per section 87113 The license shall be posted in a prominent location in the licensed facility accessible to public view. There were three private client's rooms and two rooms were for the administrator. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with hot water was measured at 118.4 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and is for private use for the administrator. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies were inaccessible to clients in care. LPA's did notice knife drawer was unlocked, but administrator was able to fix the lock. Facility had adequate supplies of personal protective equipment in place. LPA's did recommend Administrator to obtain more mask for staff use.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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 04/15/2022 08:33 AM - 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 HOMES	FACILITY NUMBER: 306005904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Request a transfer of a criminal record clearance as specificed in section 87355(c) or
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidence by: One out of two staff members are not associated to the facility. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Licensee agrees to associate staff member to the facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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: 04/14/2022

NARRATIVE

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Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA observed no shaded area in backyard. License agrees to to get an umbrella. Per section 8721899 (h)(2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable and appropriately equipped for outdoor use. Laundry room was in good repair and first aid kits were and locked. Kitchen was in good repair with knifes kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPAs discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, one deficiency was noted in areas observed. One citation was issued. An advisory was issued today. Based on the observations made during today’s visit, deficiencies are being sited per Title 22 Division 6 Chapter 8 of the California Code of Regulations,

LPA Tapia conducted an exit interview with AD Tomas Adams and copy of this report

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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