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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600471
Report Date: 07/21/2021
Date Signed: 07/21/2021 02:09:28 PM

Document Has Been Signed on 07/21/2021 02:09 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANDREW ELIJAHS GUEST HOMEFACILITY NUMBER:
015600471
ADMINISTRATOR:JUNTILLA, ALEX P.FACILITY TYPE:
740
ADDRESS:1234 PURDUE STREETTELEPHONE:
(510) 614-2285
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 6CENSUS: 6DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Alex JuntillaTIME COMPLETED:
02:15 PM
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On 07/21/2021 at 1:09pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Licensee, Alex Juntilla and explained the purpose of the visit.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed food and paper supplies are sufficient. COVID-19 screening questions and sign-in were maintained at the facility for all staff, residents, and visitors. Hand sanitizer is provided at facility entryway. Common areas are disinfected at least twice a day. Carbon monoxide and smoke detector were working.

During record review, LPA observed facility has a copy of Mitigation Plan on file.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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