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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601244
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:03:44 PM


Document Has Been Signed on 09/11/2024 01:03 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 ELIJAH'S GUEST HOME IIFACILITY NUMBER:
015601244
ADMINISTRATOR:JUNTILLA, ALEX & CECILIAFACILITY TYPE:
740
ADDRESS:1589 BEECHWOOD AVENUETELEPHONE:
(510) 614-6778
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:6CENSUS: 6DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alex Juntilla, AdministratorTIME COMPLETED:
01:30 PM
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On 09/11/24 at 11:30 AM, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct a required annual inspection. LPA met with Administrator (ADM) and explained the purpose of the visit. LPA observed ADM certificate # 6020375740 which expires 11/17/2024.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms of which 4 bedrooms are occupied by the residents and 1 bedroom is 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 75 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 107 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 observed fully charged and was last serviced on 12/20/23. First aid kit was observed to be complete. Emergency fire and disaster drills are conducted every quarter and was last conducted on 07/22/24. LPA reviewed 5 residents records and 3 staff records and observed all were complete.

No deficiencies cited during visit. 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: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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