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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881509
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:39:42 PM

Document Has Been Signed on 11/19/2024 12:39 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANDERSON ADULT HOME 2FACILITY NUMBER:
331881509
ADMINISTRATOR/
DIRECTOR:		GORE II, ALLISON JFACILITY TYPE:
735
ADDRESS:28865 DRACAEA AVENUETELEPHONE:
(951) 208-0942
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:32 AM
MET WITH:Danasia Smith, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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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. Information was obtained indicating the staff member was working at the facility during the pending background check clearance.

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. S1 was not observed to be present during the visit. A staff schedule revealed S1 was listed and had worked on their own on 11/18/2024. Client interviews were conducted with two of four clients who were present during the LPA's visit. One client interview revealed S1 has worked in the home, for approximately one month, in which S1 has provided care and supervision to clients in care. One staff interview revealed S1 has been present and working in the home since 10/22/2024. The staff interview revealed S1 ended their training on 11/04/2024 and began working independently on 11/05/2024. Staff interviews revealed a Background Check Clearance was obtained from the Department; however, proof of the clearance could not be provided. Review of S1's file was attempted, in order to locate possible fingerprint clearance records; however, the file was not available at the facility.

Therefore, based on interviews and records, a citation and civil penalty will be issued due to S1 working at the facility without a California clearance or a criminal record exemption. This report was reviewed with House Manager Smith and a copy was provided, along with LIC 421BG, LIC 811 and instructions on appeal rights. 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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Document Has Been Signed on 11/19/2024 12:39 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 11/19/2024 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANDERSON ADULT HOME 2
FACILITY NUMBER: 331881509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/20/2024
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department
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House Manager reported S1 was removed from the schedule on 11/19/2024 and a new schedule would be submitted to the Department by the POC due date.
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This requirement was not met, as evidenced by: Based on interviews and records, S1 was working in the facility without a California clearance or a criminal record exemption. This poses an immediate threat to the health, safety and personal rights of the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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