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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423929
Report Date: 04/20/2022
Date Signed: 04/20/2022 02:13:55 PM

Document Has Been Signed on 04/20/2022 02:13 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
, CA 92507
FACILITY NAME:ANDERSON ADULT HOME IIIFACILITY NUMBER:
366423929
ADMINISTRATOR:PAULA WILSONFACILITY TYPE:
735
ADDRESS:13599 MESA LINDA AVE.TELEPHONE:
(760) 244-2775
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 4DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sonya Perez Direct Support Staff IITIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate annual inspection, LPA met with Sonya Perez Direct Support Staff II

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the facility inside and out and there were no health and safety concerns. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The outdoor and indoor hallways were also free of obstruction.

Cleaning supplies, emergency food and supplies are locked in locked garage.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review. LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE.

The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water 102.9 degrees f.

There was one deficiency cited during this visit

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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 3
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
, CA 92507
FACILITY NAME: ANDERSON ADULT HOME III
FACILITY NUMBER: 366423929
VISIT DATE: 04/20/2022
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During the tour, LPA confirmed that Staff had criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the clients in care. LPA was informed that S1 has worked at this facility since September 19,2020 A civil penalty of $500 was assessed on 4/20/2022.

Refer to LIC809D for deficiency cited. An exit interview was conducted where this report, LIC809D was provided to Sonya Perez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 04/20/2022 02:13 PM - It Cannot Be Edited


Created By: Bernadette Allen On 04/20/2022 at 01:48 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
, CA 92507

FACILITY NAME: ANDERSON ADULT HOME III
FACILITY NUMBER: 366423929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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During the tour, LPA confirmed that Staff had criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the clients in care. LPA was informed that S1 has worked at this facility since March 9,2022. A civil penalty of $500 was assessed on 4/20/2022.
POC Due Date: 04/21/2022
Plan of Correction
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The LIC9182 and Identification was provided at the time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
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