<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 12:19:02 PM

Document Has Been Signed on 08/20/2021 12:19 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
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 08/20/21 at 12:10pm, Licensing Program Analyst (LPA) D. Panlilio conducted a Component III Review, for the Pre-licensing Inspection which was conducted on this date.

LPA reviewed Component III with applicant Rolando Gil. Common deficiencies cited at ARF facilities were discussed and how to mitigate their occurence. Applicant has knowledge / understanding of Title 22 regulations and agreed to be in compliance.

A license has not yet been granted to this facility. Licensure is subject to final review and approval by the Centralized Applications Unit. Licensee is not to accept residents until notified by Community Care Licensing that the license has been approved.

See LIC809 (Pre-licensing Inspection) Report dated 08/20/21, for the Pre-licensing Inspection conducted in relation to this report.
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