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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600812
Report Date: 12/26/2024
Date Signed: 12/26/2024 03:17:55 PM

Document Has Been Signed on 12/26/2024 03:17 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANDRE ALEXIS GUEST HOMEFACILITY NUMBER:
015600812
ADMINISTRATOR/
DIRECTOR:		JUNTILLA, ALEX P.FACILITY TYPE:
740
ADDRESS:1617 CHARLES ROADTELEPHONE:
(510) 430-1351
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 5DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Alex Juntilla, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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On 12/26/2024 at 10:25 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 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 all six (6) may be non-ambulatory and two (2) hospice waiver.

LPA toured facility with Alex inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 107.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Smoke detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/06/2024. Emergency Disaster Plan was last posted on 01/10/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/02/2024.

At 10:55 AM, LPA reviewed 5 residents records. At 11:18 AM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and 3 of 3 are associated to the facility. At 1:20 PM, LPA reviewed samples of resident’s medications.

Continue LIC 809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANDRE ALEXIS GUEST HOME
FACILITY NUMBER: 015600812
VISIT DATE: 12/26/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 01/03/2025:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC9020 Register of Residents
LIC 610E Emergency Disaster Plan
Liability Insurance
Auto Insurance


THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 10:24 AM, LPA observed medication cabinet in the kitchen area unlocked and accessible to residents.

At 10:46 AM, LPA observed second bolt lock on side gate leading to back yard. Civil penalty of $500 is being assessed.

At 11:10, LPA observed that R1, R2, R3, R4, and R5 did not have an Appraisal Needs and Services Plan in file.

At 12:45 PM, LPA observed the carbon monoxide detector not operating.


The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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Page: 4 of 6
Document Has Been Signed on 12/26/2024 03:17 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/26/2024 at 02:02 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANDRE ALEXIS GUEST HOME
FACILITY NUMBER: 015600812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a second bolt which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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The Administrator agrees to remove the second bold from the gate and send proof to CCLD by POC date. Civil Penalty of $500 is assessed.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having the medication cabinet unlocked in the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Administrator locked the medication cabinet during the visit. Deficiency cleared.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/26/2024 03:17 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/26/2024 at 02:02 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANDRE ALEXIS GUEST HOME
FACILITY NUMBER: 015600812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in having a carbon monoxide detector not operating which poses a potential health and safety risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Administrator agrees to buy a new carbon monoxide and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87463(c)
(c)The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not havig R1, R2, R3, R4, and R5 Appraisal Needs and Service Plan which poses a potential health and safety risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Administrator agrees to have an Appraisals Needs and Service Plan for all residents and send proof to CCLD by POC date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


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