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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603880
Report Date: 09/23/2024
Date Signed: 09/23/2024 10:14:06 AM

Document Has Been Signed on 09/23/2024 10:14 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ADAM'S ARFFACILITY NUMBER:
374603880
ADMINISTRATOR/
DIRECTOR:		CROW, DARAFACILITY TYPE:
735
ADDRESS:927 TANYA LANETELEPHONE:
(760) 728-4206
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 5DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Caregiver, Arturo VargasTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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On 9/23/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Arturo Vargas who was informed of the purpose of the visit. The facility has a fire clearance for five (5) ambulatory clients and one (1) non-ambulatory client, and serves adults ages 18 through 59. During the visit, there was one (1) staff present and LPA was informed all five (5) clients were attending day program.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a one (1) story home with five (5) client bedrooms, two (2) bathrooms, a staff room, two (2) living rooms, a kitchen, dining room and attached garage. Caregiver Vargas tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen. All client bedrooms had the required furniture and lighting. Bathrooms had a working toilet and wash basin. Indoor and outdoor pathways were free of obstructions. Outdoor shaded seating area is available for the clients in care. No bodies of water were observed on the premises. LPA observed a hallway cabinet with additional hygiene supplies and clean towels available for the clients. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and more than a 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. Medications are secured in a locked hallway closet. LPA reviewed the physical medications for two (2) clients along with their Medication Administration Record and did not discover any discrepancies. Staff present has a criminal record clearance and is associated with the facility. LPA reviewed two (2) client files, which had the Department's required records. Cleaning solutions and disinfectants are secured in cabinet above the laundry service.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Vargas.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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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