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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202877
Report Date: 02/02/2023
Date Signed: 02/02/2023 10:25:52 AM

Document Has Been Signed on 02/02/2023 10:25 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ANDREA'S ELDERLY CARE FACILITY 1FACILITY NUMBER:
435202877
ADMINISTRATOR:VALDEZ, JOWELLFACILITY TYPE:
740
ADDRESS:804 HAMANN DRIVETELEPHONE:
(408) 490-4758
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 12CENSUS: 0DATE:
02/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jowell Valdez, Percival and Felina RoqueTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) David Marrufo, Simi Rai, and Manuel Monter conducted an unannounced Pre-Licensing Visit and met with Licensees Percival and Felina Roque and Administrator Jowell Valdez.

LPAs toured the facility inside and out. 9 out of 9 resident rooms were toured. The facility had a visitor screening area with thermometer and symptom screening forms. Each room had functioning lights, beds with bedding, and dressers. The bedrooms with outdoor exits had functioning door opening detectors and the outside areas were clear of obstructions. The facility kitchen and food storage areas were observed. 3 out of 3 hallway bathrooms were observed and the water temperatures were measured at 108 F. Each bathroom had available soap, paper towels, and hand washing signs. The facility had a 30-day supply of PPEs. The facility first aid kit was observed to be complete.

No residents were observed at the facility during visit.

2 out of 2 carbon monoxide detectors were tested and found to be functioning properly. The facility had locked storage areas for medications, records, and cleaning supplies.

LPAs reviewed Component III presentation with facility licensees and administrator.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Licensees Percival and Felina Roque and Administrator Jowell and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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