331881508-2-29-2024-18-AS-YDEO-D2WRVN-20240229122150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881508
Report Date: 02/29/2024
Date Signed: 02/29/2024 12:22:20 PM

Document Has Been Signed on 02/29/2024 12:22 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ANDERSON ADULT HOME I		FACILITY NUMBER:	331881508
ADMINISTRATOR:	GORE II, ALLISON J		FACILITY TYPE:	735
ADDRESS:	12383 KASOTA COURT		TELEPHONE:	(951) 221-1849
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY: 6		CENSUS: 4	DATE:	02/29/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Allison (Al) Gore, Licensee		TIME COMPLETED:	12:30 PM

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) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 09:45 AM, LPA met with Licensee/Administrator Allison (Al) Gore. An initial application for Change of Ownership to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 12/20/2023 for a total capacity of six (6) ambulatory, zero (0) bedridden residents and zero (0) non-ambulatory residents. Licensee Al Gore stated that he requested a total capacity of four (4) capacity for ambulatory. Fire clearance was granted on 1/11/2024. Licensee Al Gore contacted Diamond Law, CAB and Ms. Law will check the application and contact the Fire Department regarding the fire clearance. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house that is used for storage. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom #1, #2, #3 and #4 will accommodate any ambulatory resident. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANDERSON ADULT HOME I	FACILITY NUMBER: 331881508
	VISIT DATE: 02/29/2024

NARRATIVE

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Bathrooms:
The two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 11:04 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.1 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the staff office. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents supplies were observed in garage away from residents. Cleaning supplies were observed in a red locked cabinet.
Family room:
There was a living/family room with enough seating for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens and hygiene was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio table and sufficient chairs were observed in the backyard; portable canopy (2) covers need to be replaced. There was a gate on the South side that doesn't have a self-latching lock on the exterior doors; needs to be installed. All outdoor pathways were free of obstructions; however grass areas need to be maintained.
Emergency Phone Numbers, and Exit Plan:
Facility sketch, Right of Counsel, Residents Personal rights, Let-Us-No poster were observed posted in the family room.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANDERSON ADULT HOME I	FACILITY NUMBER: 331881508
	VISIT DATE: 02/29/2024

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General items:
Three (3) fire extinguishers were charged and located in the kitchen, garage and office. Eight (8) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the staff office. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and 72-hour food supply was observed. Diamond Law, CAB contacted Licensee and LPA Delgado during the inspection that Fire Department will be updating their fire clearance by the end of the day. Component III was completed on this day as well.

Pre-Licensing is incomplete and the following corrections to be resolved by 3/11/2024:

install self-latching lock on gate door
obtain additional PPE supplies
replace portable canopy covering
remove debris in the backyard, clean up grass areas
need updated LIC200 Application with correct capacity
need updated Fire Clearance

An exit interview was conducted, and a copy of this report was given.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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