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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600812
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:35:18 PM


Document Has Been Signed on 01/18/2024 12:35 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:ANDRE ALEXIS GUEST HOMEFACILITY NUMBER:
015600812
ADMINISTRATOR:JUNTILLA, ALEX P.FACILITY TYPE:
740
ADDRESS:1617 CHARLES ROADTELEPHONE:
(510) 430-1351
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 3DATE:
01/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alex Juntilla, AdministratorTIME COMPLETED:
01:30 PM
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On 01/18/24 at 12PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health & safety check as a result of the department receiving a priority 2 complaint. LPA explained the purpose of the visit with administrator (ADM).

During health and safety check, LPA observed a total of 3 staff members and 3 residents at facility. LPA toured facility with staff (S1), including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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