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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202834
Report Date: 08/08/2024
Date Signed: 08/08/2024 05:01:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/08/2024 05:01 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ANDREA'S ELDERLY CARE FACILITY #2FACILITY NUMBER:
435202834
ADMINISTRATOR/
DIRECTOR:		ROQUE, PERCIVALFACILITY TYPE:
740
ADDRESS:1525 FRANKLIN ST.TELEPHONE:
(408) 605-2033
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 6CENSUS: 6DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Back-Up Administrator/Lead Staff, Lerma EspirituTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Back-Up Administrator/Lead Staff, Lerma Espiritu. LPA Rai observed 2 staff and 6 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the basement of the facility and observe the space being used as storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai reviewed the facility sketch on file as well as the facility sketch posted on the bulletin wall at the facility, which describe the floor plan to have 4 bedrooms, not 5 as observed during visit. LPA Rai spoke with Licensee, Felina Roque who stated the 5th bedroom was added to the facility and they have a city permit to build the room. LPA Rai requested for Licensee Felina to submit the updated facility sketch.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.4 degrees F - 105.7 degrees F. The water temperature in the kitchen sink was 105.9F.

Fire extinguisher was observed and inspected on 10/10/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills was conducted on 07/08/2024 and 07/10/2024.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ANDREA'S ELDERLY CARE FACILITY #2
FACILITY NUMBER: 435202834
VISIT DATE: 08/08/2024
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LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records. During visit, LPA Rai observed 5 out of 5 resident beds had attached half-bed rails. LPA Rai reviewed resident files and observed a written order to use half-bed rails for mobility.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Back-Up Administrator/Lead Staff, Lerma Espiritu and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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