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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600812
Report Date: 12/26/2023
Date Signed: 12/26/2023 02:05:53 PM

Document Has Been Signed on 12/26/2023 02:05 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:ANDRE ALEXIS GUEST HOMEFACILITY NUMBER:
015600812
ADMINISTRATOR:JUNTILLA, ALEX P.FACILITY TYPE:
740
ADDRESS:1617 CHARLES ROADTELEPHONE:
(510) 430-1351
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 5DATE:
12/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alex Juntilla, AdminstratorTIME COMPLETED:
02:15 PM
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On 12/26/23 at 12:30 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to complete the 1-Year Annual Required inspection. LPA met with Administrator, Alex Juntilla and explained the purpose of the visit. The facility’s fire clearance was approved for 6 residents.

Emergency Disaster Plan was last posted on 12/26/23. Emergency disaster drill was last conducted on 10/06/23.

LPA reviewed 5 residents records and 5 staff records; all were complete. LPA also reviewed a sample of resident’s medications.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023
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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