<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201097
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:22:58 PM

Document Has Been Signed on 08/20/2021 12:22 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:CASA ANDRES, INCFACILITY NUMBER:
079201097
ADMINISTRATOR:MENDOZA, ROLANDO GILFACILITY TYPE:
735
ADDRESS:3908 BOULDER DRTELEPHONE:
(502) 544-3068
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
08/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rolando Gil, Applicant/LicenseeTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/20/2021 at 11:00am Licensing Program Analyst (LPA) D. Panlilio conducted an announced pre-licensing inspection and met with Rolando Gil, Applicant/Licensee. LPA observed this is a brand new facility with no clients. Applicant stated once license is issued, he will apply vendorization with Regional Center of the East Bay to operate a level 4I home.

LPA toured the clients bedrooms, bathrooms, dining room, common living areas, kitchen, and backyard. There are three (4) bedrooms and two (3) bathrooms. There is sufficient lighting around the facility. Clients' rooms are equipped with the proper furniture, bedding and lighting. Passageways and hallways are free of obstruction. Hot water temperature is measured at 114.6 degrees Fahrenheit. LPA observed locked cabinets that will store medications, toxins and sharps. Required posters are posted on the wall. Thermostat in hallway showed temperature as 73 degrees F. Emergency disaster plan dated 06/16/21. Two fire extinguishers were last serviced on 07/23/21. First Aid kit was complete. Carbon monoxide and smoke detectors were in working condition.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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 1