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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002847
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:24:34 AM


Document Has Been Signed on 01/18/2024 10:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ADAMS RESIDENTIAL CARE SERVICES LLCFACILITY NUMBER:
345002847
ADMINISTRATOR:CAILING, ESTELITAFACILITY TYPE:
740
ADDRESS:7809 OLD AUBURN RDTELEPHONE:
(916) 390-6144
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Adam Dickey, Co-Administrator TIME COMPLETED:
10:25 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) Sabrina Calzada arrived announced on 1/18/24 to conduct a scheduled annual since there are currently still no clients in care. LPA met with Adam Dickey, Co-Administrator, who scheduled the appointment. There are no clients at this time due to waiting for vendorization from the Regional Center. Co-Administrator expects vendorization to occur in the next (2) months.

LPA and Co-Administrator toured the interior of the facility, including (4) client bedrooms, (3) staff rooms, (2) additional bedrooms, (2) client bathrooms, (1) staff bathroom, and the common areas, including a client lounge area, kitchen, and laundry room. LPA observed all rooms, including the client bedrooms, to be completely furnished and with window coverings. There are dishes, flatware and glassware in the kitchen. There are linens and towels also on hand as well as games, activities and art supplies for the clients.

Sharps and toxins will be secured in the kitchen and medications will be secured in the laundry area. LPA observed all required posters up. Fire extinguisher was serviced August 2023.

LPA observed (4) client binders prepared with blank paperwork and tab dividers. Staff binders will need to be made before clients move in.

Co-Administrator, Adam, to notify the Department when the facility is vendorized. The facility will be vendorized for (4) clients and as a level 4H home.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided to Co-Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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