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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881508
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:20:12 PM

Document Has Been Signed on 01/18/2024 03:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ANDERSON ADULT HOME IFACILITY NUMBER:
331881508
ADMINISTRATOR:GORE, ALLISON J IIFACILITY TYPE:
735
ADDRESS:12383 KASOTA COURTTELEPHONE:
(951) 221-1849
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 4DATE:
01/18/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Allison J GoreTIME COMPLETED:
03:00 PM
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Facility Type: ARF
Application Type: CHOW-EAO
Capacity: 6
Census (if any clients in care): 4
COMP II Participants: Allison J Gore (Licensee/Administrator)
Interview Method: Virtual interview via Microsoft Teams


On January 18, 2024, applicant(s)/administrator participated in COMP II for the below pending facilities: Anderson Adult Home I/331881508 , Anderson Adult Home 2/331881509. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and administrator conf3irmed 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 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 readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Diamond Law
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)
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