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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530323
Report Date: 02/26/2025
Date Signed: 02/26/2025 01:44:18 PM

Document Has Been Signed on 02/26/2025 01:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANDERSON ADULT HOME 2FACILITY NUMBER:
365530323
ADMINISTRATOR/
DIRECTOR:		GORE, ALLISON J IIFACILITY TYPE:
735
ADDRESS:15614 PEARMAIN STREETTELEPHONE:
(951) 649-9418
CITY:ADELTANOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 0DATE:
02/26/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Allison Gore-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:58 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived to conduct an announced Pre-Licensing visit for a change of location licensure. LPA was greeted by Licensee, Allison Gore and General Manager, Beverly Harris. LPA introduced self and stated purpose of the visit. LIC200 application was submitted on 10/29/24 for (4) ambulatory clients. Fire Safety Inspection clearance was granted for (4) ambulatory clients on 12/20/24. LPA toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with (4) client bedrooms, (2) bathrooms, office, living room, family room, dining area, kitchen, laundry room, backyard, and attached garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.

Bedrooms: All bedrooms accommodate ambulatory clients in each room. All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Bathrooms: The bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent, and chemicals are stored in locked compartments. There was non-perishable food and perishable food. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the bathroom faucet measured at 109.8 degrees fahrenheit. A functional washer and dryer are located inside the laundry room.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANDERSON ADULT HOME 2
FACILITY NUMBER: 365530323
VISIT DATE: 02/26/2025
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Living/Family room: There was a furnished family room with games observed. There was a living room with a tv and an inaccessible fireplace observed.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a closet.

Yards/Outside: A shaded covered patio with seating areas and a gate on the left and right side of the house that leads into the backyard. There are no firearms, ammunition, swimming pool or bodies of water observed. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Floor plan, house rules, CCL complaint poster, visitors policy, personal rights were observed posted.

General items: The smoke and carbon monoxide detectors were tested and are operable. There are (2) fully charged fire extinguishers observed. Client/Staff records stored inside the locked filing cabinets. First Aid kit with required components, and a locked compartment for medication storage was observed. The facility has a functioning telephone and line.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. LPA completed COMP III with the Licensee and General Manager at the conclusion of the inspection.

Licensee will be notified once facility is licensed. An exit interview was conducted, and this report was discussed and provided to Licensee, Allison Gore.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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