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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202834
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:49:15 PM

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 #2FACILITY NUMBER:
435202834
ADMINISTRATOR:ROQUE, PERCIVALFACILITY TYPE:
740
ADDRESS:1525 FRANKLIN ST.TELEPHONE:
(408) 605-2033
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 0DATE:
08/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Felina and Percival RoqueTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted a pre-licensing inspection today. LPA met with Administrators (ADM) Felina and Percival Roque.

At around 1:31pm, LPA toured the facility interior and exterior, including living room, receiving area, 4 resident bedrooms, 2 bathrooms, kitchen, dining area, garage, basement, and additional residential unit (ARU).

The facility is equipped with connected smoke detectors. The smoke detector located in the hallway by the entry was tested and observed working. A carbon monoxide detector located in bedroom #1 was tested and observed working. 2 fire extinguishers was observed and were noted to have been inspected on February 2021. The kitchen, dining and living room were observed in good repair.

Resident bedrooms were observed to be unfurnished but in good repair. Bathrooms were observed clean and equipped with grab bars and non-skid mats. The water temperature in bathroom #1, #2, and in ARU were observed to be between 116.5* F and 119.1* F. Centrally stored medication cabinet and cleaning supplies observed with locks. A complete first aid kit was inspected. The backyard was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was waived for this facility due to Administrator’s prior experience. No issues noted during the pre-licensing inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report provided to Felina and Percival Roque
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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