Adams Family Homes

Type of visit: Required - 1 Year

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 Freddy Gambol and the purpose of the inspection was discussed. 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 resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, and faucets and toilets were operational. Water temperature tested between 108.5 - 112.8 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 was observed to be centrally stored and locked. LPA reviewed three resident files. One of three resident files did not have a medical assessment signed by a licensed medical professional acting within the scope of their practice and made within the last year; a Deficiency was cited on today’s date. Two of three resident files did not include results of examination for TB; a Deficiency was cited on today’s date. (Cont. LIC809-C) Staff files did not contain any documentation of staff training conducted in the past year; a Deficiency was cited on today’s date. 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 and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Thomas Adams. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on September 25, 2024. Structure: The facility is a one-story house with three resident bedrooms, one staff bedroom, two bathrooms, a living room, a kitchen, a dining room, a family room, a laundry room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the laundry room. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements. Resident & Staff Files: Records will be kept in a locked file cabinet. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: Fire extinguisher is fully charged. Reading Material, Games, Equipment & Materials: The facility has magazines, arts and crafts supplies stored in living room and additional recreational materials for resident use will be maintained. Fire clearance: Was approved by a fire inspector of City of Placentia Fire Department on October 15, 2024. No special conditions noted. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: There is one staff bedroom. Bathrooms: All bathrooms have working plumbing. Hot water measured between 114.9- and 115.3-degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway storage closet. Emergency Phone Numbers, Exit Plan & Menu: Posted and available, means of exiting, and emergency phone numbers. Food menu is also posted and available. Food Service: A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas burner stove, refrigerator, microwave, washer, and dryer are operational. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Jan 3, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 3 COMP II Participants: Name - Shayley Adams CEO/ Thomas G Adams Administrator Interview Method: Telephone interview On November 25, 2024, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-Licensing Readinessthe state’s words, verbatim · CDSS document, Nov 25, 2024