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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881508
Report Date: 11/19/2024
Date Signed: 11/19/2024 11:14:00 AM

Document Has Been Signed on 11/19/2024 11:14 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:ANDERSON ADULT HOME IFACILITY NUMBER:
331881508
ADMINISTRATOR/
DIRECTOR:		GORE II, ALLISON JFACILITY TYPE:
735
ADDRESS:12383 KASOTA COURTTELEPHONE:
(951) 241-5614
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 3DATE:
11/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Danasia Smith, House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to follow up on a pending exclusion order of a possible staff member. The LPA met with House Manager, Danasia Smith, and informed her of the purpose for the visit.

The Department was made aware of a pending Administrative Action, Exclusion, of a possible staff member, Staff One (S1), after a transfer request for the individual was obtained. During the visit the LPA conducted staff and client interviews, reviewed and obtained relevant records, and toured the interior and exterior areas of the home. Client interviews were attempted with two of three clients who were present during the LPA's visit; however, statements regarding the possible presence of the staff member could not be obtained. Two staff interviews revealed S1 has been present in the home; however, the purpose for the staff member being in the home was for training purposes. One of two staff interviews revealed S1 did not provide care to the clients and was not left alone with the clients.

No health and safety concerns were observed during the visit. No citations will be issued. This report was reviewed with House Manager Smith and a copy was provided. House Manager Smith had no questions at the conclusion of the LPA's visit.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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