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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601244
Report Date: 09/27/2021
Date Signed: 09/27/2021 03:00:04 PM

Document Has Been Signed on 09/27/2021 03:00 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: 6DATE:
09/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Nolan Escuadro, Care StaffTIME COMPLETED:
03:00 PM
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On 9/27/2021 starting at 2:50pm, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct an Infection Control Inspection. LPA met with Nolan Escuadro and explained the purpose of the visit. Based on record review, LPA observed facility already had completed inspection on 7/12/2021 by LPA A. O'hollaren.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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