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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601244
Report Date: 07/12/2021
Date Signed: 07/12/2021 02:55:53 PM

Document Has Been Signed on 07/12/2021 02:55 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 ELIJAH'S GUEST HOME IIFACILITY NUMBER:
015601244
ADMINISTRATOR:JUNTILLA, ALEX & CECILIAFACILITY TYPE:
740
ADDRESS:1589 BEECHWOOD AVENUETELEPHONE:
(510) 614-6778
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 6CENSUS: 5DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Alex JuntillaTIME COMPLETED:
03:00 PM
NARRATIVE
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On 07/12/2021 at 1:12pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Staff Norma Cabrera and explained the purpose of the visit. Licensee Alex Juntilla arrived at approximately 1:20pm.

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 including COVID-19 symptoms posted in the common area. All hand washing stations have a hand washing sign posted. Common bathroom is equipped with soap, paper towels and garbage with a lid. LPA observed food and paper supplies are sufficient. Resident and staff's temperatures are checked daily. Common areas are disinfected at least once a day.

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

LPA observed fire extinguisher was last serviced September 2019.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct deficiency may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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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Document Has Been Signed on 07/12/2021 02:55 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 07/12/2021 at 02:38 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: ANDREW ELIJAH'S GUEST HOME II
FACILITY NUMBER: 015601244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


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. LPA observed fire extinguisher was last serviced September 2019 in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2021
Plan of Correction
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By POC date licensee agrees to have fire extinguisher serviced or replaced, and submit a copy of tag to CCL by fax or email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021


LIC809 (FAS) - (06/04)
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