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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425507
Report Date: 05/04/2023
Date Signed: 05/04/2023 05:28:58 PM

Document Has Been Signed on 05/04/2023 05:28 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 IVFACILITY NUMBER:
366425507
ADMINISTRATOR:PAULA WILSONFACILITY TYPE:
735
ADDRESS:14558 CLYDESDALETELEPHONE:
(760) 991-6026
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 6CENSUS: DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Porsha Hull-DSPTIME COMPLETED:
05:30 PM
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On 05/04/23 at 03:10 PM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by DSP, Porsha Hull. LPA observed that there is currently 3 clients present in the home. LPA toured the facility inside and outside with Hull. Later during the tour, Manager Beverly Harris arrived to complete the tour.

The facility has 5 bedrooms, 2 bathrooms, a kitchen, dining area, 2 living rooms, attached 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 68 degrees F temperature. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in a cabinet in the hallway of the residence. LPA inspected client's bathroom; bathroom was clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet, which tested within regulation at 117.8 degrees F. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility had emergency supplies for clients. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Yards/Outside:
One shaded front 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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 IV
FACILITY NUMBER: 366425507
VISIT DATE: 05/04/2023
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry fully stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly. Emergency food and water were observed inside the garage.
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Record Review: LPA reviewed the clients files along with the staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

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

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

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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