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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201097
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:36:22 PM

Document Has Been Signed on 08/03/2022 12:36 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:GIL MENDOZA, ROLANDOFACILITY TYPE:
735
ADDRESS:3908 BOULDER DRTELEPHONE:
(502) 544-3068
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 2DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lidia Chumbipuma CaregiverTIME COMPLETED:
12:40 PM
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On 8/3/2022 at 11:45AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Lidia Chumbipuma, Caregiver and explained the purpose of the visit. Administrator, Rolando Mendoza arrived at 12:04PM.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, backyard, and kitchen. LPA observed cough etiquette 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 hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 129.4 degrees Fahrenheit. Fire extinguisher last serviced on 8/1/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Infection Control Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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