345920374-4-3-2026-59-AS-SCAA-DSSPLH-20260403112447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345920374
Report Date: 04/03/2026
Date Signed: 04/03/2026 11:24:56 AM

Document Has Been Signed on 04/03/2026 11:24 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 LLC #2		FACILITY NUMBER:	345920374
ADMINISTRATOR/ DIRECTOR:	DICKEY, ADAM		FACILITY TYPE:	740
ADDRESS:	8139 B WACHTEL WAY		TELEPHONE:	(916) 390-6144
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY: 4		CENSUS: 0	DATE:	04/03/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Adam Dickey, Administrator and Kellie Welker, Administrator Designee		TIME VISIT/ INSPECTION COMPLETED:	11:30 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 to the facility to conduct a scheduled Pre-Licensing Inspection on April 3, 2026 at 9:30 am. LPA met with Adam Dickey, Administrator and Kellie Welker, Administrator Designee. There is a pending application for a Level 5, RCFE facility, vendorized through the Regional Center, and there are currently (0) residents in care. The home has been recently remodeled in all rooms and the outside areas as well. Fire clearance has approved room #4 for a non-ambulatory resident and rooms #1,2 and 3 are approved for ambulatory residents. LPA and the Administrators toured the interior/exterior of the facility, including the common areas, (4) client bedrooms, (1) staff room, bathrooms, kitchen, office area, laundry and patio/backyard area. The facility was observed to be clean, newly remodeled, with new furniture and lighting throughout. Resident bathrooms have grab bars and skid-resistant flooring and hygiene supplies. LPA observed new dishes, glassware, flatware and cook ware in the kitchen and 7+days of non-perishable food. Toxins will be locked under the kitchen sink and in/near the laundry area. Sharps will be locked in the kitchen and medications will be secured in a closet with a electronic keypad. All client rooms have a locking mechanism in place and the all exit doors have alerts. There is sufficient linens/blankets/hygiene supplies. Smoke/monoxide alarms work and the fire extinguisher was last serviced 3/31/2026. Hot water measured 114F in the kitchen. Land line number obtained. All required posting are visible in the common area. The backyard has lots of seating, fruit trees and a covered activity area. Resident and staff binders are organized. RCFE Administrator Certificate #7023412740 (exp 9/28/26). Comp III was completed during today's inspection. The Pre-Licensing is complete and this facility has no deficiencies. LPA to notify the analyst in the Centralized Applications Bureau* Exit interview. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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