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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202834
Report Date: 08/05/2022
Date Signed: 08/05/2022 03:03:44 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/05/2022 03:03 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, 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: 5DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Felina RoqueTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Felina Roque. Upon arrival, staff Lerma Espiritu (S1) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. There were no COVID posters on the main door, ADM stated the facility will put the COVID posters on in 3 days. COVID posters were observed in the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. No COVID questionnaires was observed. ADM stated the facility will put the COVID questionnaires at the screening station in 3 days. Living room, kitchen, dinning area and two restrooms were inspected. All trash cans were observed with covers. Some paper towels were observed without holder. ADM stated the facility will put the paper towels with holders in 3 days. Four single resident bedrooms, one resident shared room and garage were inspected. Two staff live-in rooms are in facility. No posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. ADM stated the facility will put the posters of washing hands for 20 seconds by the sinks in 3 days. Cloth towels were observed in kitchen and restrooms. The beds in shared room were observed at 6 feet apart. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 115 degree F in facility. Five residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 06/21/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Basement was inspected. Basement is used as storage room.

ADM stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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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