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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600471
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:32:33 PM


Document Has Been Signed on 10/20/2023 01:32 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:ANDREW ELIJAHS GUEST HOMEFACILITY NUMBER:
015600471
ADMINISTRATOR:JUNTILLA, ANDREW ELIJAH CFACILITY TYPE:
740
ADDRESS:1234 PURDUE STREETTELEPHONE:
(510) 614-2285
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:6CENSUS: 4DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alex Juntilla, AdministratorTIME COMPLETED:
01:45 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 10/20/23 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Alex Juntilla and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory clients.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms of which 4 bedrooms are occupied by the residents and 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/08/22. First aid kit was observed to be complete. Emergency disaster drills are conducted quarterly.

LPA reviewed 4 residents records and 5 staff records and all were complete. LPA reviewed a sample of resident’s medications.

Updated copies of the following document were requested for facility file and are to be submitted to CCL by 10/27/23: LIC610E Emergency Disaster Plan

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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 3