331881509-2-29-2024-18-AS-YDEO-D2X2XN-20240229164725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881509
Report Date: 02/29/2024
Date Signed: 02/29/2024 04:47:35 PM

Document Has Been Signed on 02/29/2024 04:47 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 2		FACILITY NUMBER:	331881509
ADMINISTRATOR:	GORE II, ALLISON J		FACILITY TYPE:	735
ADDRESS:	28865 DRACAEA AVENUE		TELEPHONE:	(951) 208-0942
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 4		CENSUS: 3	DATE:	02/29/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Allison (Al) Gore, Licensee		TIME COMPLETED:	04:55 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 2:25 PM, 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 12/15/2023 for a total capacity of four (4) ambulatory, zero (0) non-ambulatory and zero (0) bedridden clients. Fire clearance was granted on 1/2/2024. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, three (3) resident bathrooms, living room, family room, dining area and kitchen. There was an attached three 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-bedroom #3 ceiling light is out, 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 2	FACILITY NUMBER: 331881509
	VISIT DATE: 02/29/2024

NARRATIVE

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Bathrooms:
The three (3) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of toilet paper, and soap. At 3:00 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.3 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 med cart. 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 a dining table with adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were observed in the laundry room away from residents.
Living/Family room:
There was a living/family room with seating for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in cabinets in the main hallway of the residence and hygiene supplies stored inside the med cart.
Yards/Outside:
There was no patio table observed, five sports chairs were observed in the backyard. There are enough seating and side tables in the front patio. There is a gate on the East side that needs the hook replaced with a self-latching lock. All outdoor pathways were free of obstructions; however the grass is overgrown.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in dining area, in the family room and by the garage. Let-Us-No poster, Rights of Residents observed.

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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 2	FACILITY NUMBER: 331881509
	VISIT DATE: 02/29/2024

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General items:
Three (3) fire extinguishers were charged and located in the kitchen, laundry room and main hallway. 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 kitchen. First Aid kit with required components was missing, and locked med cart 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 emergency food supply was observed. No pool or body of waters observed. Component III was completed on this day as well.

Pre-Licensing is incomplete and the following corrections to be resolved by 03/28/2024:

clean up overgrown grass in backyard
obtain patio table for backyard
obtain scissors for first aid kit
obtain paper towels
replace window screens (7)
replace light-switch plate
replace missing blind slats
remove extra things from room #3
replace bathroom trash can with lidded trash can
replace light bulb for ceiling fan in room #3
repair side gate hook with self-latching lock

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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