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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423929
Report Date: 06/17/2024
Date Signed: 06/17/2024 12:12:12 PM

Document Has Been Signed on 06/17/2024 12:12 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 IIIFACILITY NUMBER:
366423929
ADMINISTRATOR/
DIRECTOR:		PAULA WILSONFACILITY TYPE:
735
ADDRESS:13599 MESA LINDA AVE.TELEPHONE:
(760) 244-2775
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 4DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Beverly Harris- ManagerTIME VISIT/
INSPECTION COMPLETED:
12:21 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Staff, David Sturdivant and granted entrance. LPA introduced self and stated the purpose of the visit. LPA observed that there is currently no clients in the facility and all 4 are in day program. LPA toured the facility with Manager, Beverly Harris, who later arrived.

The facility has 4 bedrooms, 3 bathrooms, a kitchen, dining area, living room, family room, office, laundry room, garage and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 74 degrees fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the hallway and bathroom cabinets. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. Water temperature in the bathroom tested at 108.2 degrees fahrenheit. The facility is equipped with operating fire extinguishers, smoke alarms and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for clients/staff files, first aid kit and medication. The facility has a working telephone line. There are no pools, bodies of water, firearms or ammunition.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food. Dishes, cups, and utensils were also stored properly. Emergency food, water, comforters, supplies and emergency disaster kits were observed inside the garage.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANDERSON ADULT HOME III
FACILITY NUMBER: 366423929
VISIT DATE: 06/17/2024
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted at random and matched with the ledger. Medication was audited at random and matched with the MARS. The facility last conducted a disaster drill in June 11, 2024.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed and copies were provided to Manager, Beverly Harris.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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