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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202481
Report Date: 04/06/2021
Date Signed: 04/06/2021 11:54:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ANDREA'S ELDERLY CARE FACILITY #3FACILITY NUMBER:
435202481
ADMINISTRATOR:MARIETTA B. MINASFACILITY TYPE:
740
ADDRESS:167 BLAKE AVENUETELEPHONE:
(408) 816-7151
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:6CENSUS: 0DATE:
04/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Felina RoqueTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit today. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA spoke with licensee Felina Roque.

The purpose of the tele-visit is for the official closure of the facility Andrea’s Elderly Facility #3 with license number 435202481 due to a change of ownership. Closure notice was received by Community Care Licensing (CCL) on 08/01/20. Facility closure survey was sent to licensee via e-mail on 02/23/21.

Per licensee, most of the residents are being retained under the new licensee. One resident has moved out of the facility per resident’s decision. LPA informed licensee that a forfeiture letter will be mailed to the licensee's mailing address. LPA requested the original license be surrendered to CCL within 10 business days via mail.

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Felina Roque to sign and mail back to CCL.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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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