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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600812
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:52:52 AM


Document Has Been Signed on 12/19/2023 11:52 AM - 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: 5DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Rebeca Madrigalejos, Care StaffTIME COMPLETED:
12:00 PM
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On 12/19/23 at 10:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA spoke with Administrator, Alex Juntilla and explained the purpose of the visit. Administrator gave permission for care staff to sign the report. The facility’s fire clearance was approved for 6 residents.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 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 105.7 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,carbon monoxide detectors and fire extinguisher were in operating condition during visit.

Due to the administrator being out of town LPA will return at a later date to complete the inspection.

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: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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