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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200779
Report Date: 06/27/2022
Date Signed: 06/27/2022 10:26:52 AM

Document Has Been Signed on 06/27/2022 10:26 AM - 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:ANDALUCIA HOMEFACILITY NUMBER:
019200779
ADMINISTRATOR:LEGARDA, MARISSAFACILITY TYPE:
735
ADDRESS:1083 ANDALUCIA STREETTELEPHONE:
(650) 892-9264
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 4CENSUS: 4DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Irwyn Legarda, Direct Care StaffTIME COMPLETED:
10:40 AM
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On 6/27/2022 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Direct Care Staff, Irwyn Legarda.

Upon entry, LPA's temperature was checked. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, garage, and outdoor area. LPA observed cough etiquette, signs & symptoms, and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitor's log. LPA observed facility does have a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient.

No deficiency is being cited to this date.

Exit interview conducted. A copy of this report and provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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