435202877-1-29-2026-26-AS-MPAA-DQSL29-20260129072156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202877
Report Date: 01/23/2026
Date Signed: 01/29/2026 07:24:52 AM

Document Has Been Signed on 01/29/2026 07:24 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 1		FACILITY NUMBER:	435202877
ADMINISTRATOR/ DIRECTOR:	VALDEZ, JOWELL		FACILITY TYPE:	740
ADDRESS:	804 HAMANN DRIVE		TELEPHONE:	(408) 490-4758
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY: 12		CENSUS: 8	DATE:	01/23/2026
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:45 AM
MET WITH:	Catherine Valle - Designated Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required inspection and met with designated administrator (DADM) Catherine Valle and stated the purpose of the visit. Administrator Jowell Valdez was not available at the time of the visit due to prior commitment and corporate secretary/licensee Felina Roque arrived at the facility at 11:54 a.m. The facility is licensed to serve adults 60 and over; up to 12 may be non-ambulatory. 7 maybe bedridden in bedrooms, 2,3,4,7 8 and 9, and a hospice waiver for 5. LPA observed residents and staff present. Facility has a capacity for 12 and current census is 8. 2 out of 8 residents were at the dining room having breakfast when LPA arrived. 5 out of 8 were in their room, having breakfast, watching TV and 1 out 8 was asleep. 3 staff were present assisting residents. LPA toured the facility, including common areas, resident rooms, kitchen, bathrooms, driveway, and outdoor spaces and storage areas. Indoor temperature was within regulation of 65°F. The kitchen was sanitary and organized; knives and chemicals were locked. Food supply met requirements (2 days perishable, 7 days non-perishable). Kitchen water temperature measured at 113.3°F. Bathroom water temperature ranged from 116.6°F to 118.7°F. Refrigerator & freezer temperature is within regulation range of 40°F and freezer is at 0°F. page 1 of 2 see LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 1	FACILITY NUMBER: 435202877
	VISIT DATE: 01/23/2026

NARRATIVE

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Bathrooms are equipped with grab bars and non-skid mats; resident rooms have adequate storage. medications were locked and inaccessible to residents; first aid kit was complete. Outdoor areas were free of hazards; laundry appliances were functional, and cleaning supplies were secured. Fire, smoke, and carbon monoxide systems were operational; hallways were clear and well-lit.

LPA reviewed 4 resident (R1 to R4) and 3 staff (S1 to S3) records, centrally stored medication and destruction record, admission agreements, care plans, health screenings, and training.

Based on record review, 4 out of 4 resident record did not have the current centrally medication and destruction record available for LPA to verify and inspect. 3 Out of 3 staff record review have a fingerprint and criminal background clearance, 2 out of 3 staff have a valid 1st aid/CPR certificate. 1 out of 3 staff record is not available for review at the time of the visit. DADM stated S3 record is being updated and was left at home by DADM, S1 stated he/she has a 1st aid/CPR certificate that is valid, however, it was left at home and no one is able to take a photo for LPA to verify the information. S1 and S2 did not have proof of training at the time of the visit. S2 stated that he/she recently started at the facility on 01/19/2026 and is in the process of being trained. S2 stated that he/she was trained by another facility that he/she works for. S1 & S3 did not have proof of training at the time of the inspection.

Based on the facility record review, the facility conducted the disaster, fire and earthquake drill training on 02/10/2025, and have not conducted disaster drill training for each shift since 02/10/2025. The facility is equipped with smoke, carbon monoxide and fire alarm system and 2 fire extinguisher that was inspected on 10/06/2025.

Deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22 (See LIC 809D). An exit interview was conducted with licensee Felina Roque and designated administrator (DADM) Catherine Valle and a copy of the report and appeals rights was provided.

end of report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/29/2026 07:24 AM - It Cannot Be Edited

Created By: Maria Partoza On 01/23/2026 at 10:43 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANDREA'S ELDERLY CARE FACILITY 1	FACILITY NUMBER: 435202877
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, 1 out of 3 staff did not have the staff record at the facility, the designated administrator (DADM) stated that he/she took the file home to make a copy and did not return the record to the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2026
	Plan of Correction
1 2 3 4	LIC & DADM stated that he/she will ensure that records will be maintained at the facility at all times and will send proof of correction by 02/03/2026.

Type B

Section Cited

CCR

87465(a)(6)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6)When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of 4 Out of 4 resident records the licensee did not comply with the section cited above by not ensuring that the centrally stored medication record are maintained by the facility. LIC/ DADM stated that he/she takes the record home to get updated and is not available at the facility when requested by the LPA during inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2026
	Plan of Correction
1 2 3 4	LIC & DADM staed that centrally stored medication record will be maintained at the facility and available for when requested by the prescribing physician and the Department. LIC & DADM stated that he/she will submit a plan of correction in writing and proof of correction by the correction due date of 02/03/2026 to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/29/2026 07:24 AM - It Cannot Be Edited

Created By: Maria Partoza On 01/23/2026 at 10:51 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANDREA'S ELDERLY CARE FACILITY 1	FACILITY NUMBER: 435202877
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

§1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on record review the license did not comply with the section cited above by not ensuring that quarterly drills for each shift and type of emergency is conducted. During today's record review the last emergency training was conducted on February 10, 2025 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2026
	Plan of Correction
1 2 3 4	Licensee (LIC) & Designated Administrator (DADM) will submit a written plan of correction by the POC due date when training will be conducted. lLIC & DADM stated that he/she will conduct the first quarter training by January 24, 2026 and will send proof of training to LPA by January 26, 2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

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