<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294199
Report Date: 06/17/2021
Date Signed: 06/30/2021 10:26:57 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 #2FACILITY NUMBER:
435294199
ADMINISTRATOR:ROQUE, PERCIVAL & FELINAFACILITY TYPE:
740
ADDRESS:1720 LAURENTIAN WAYTELEPHONE:
(408) 736-3868
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Lerma Espiritu, Percival Roque and Felina RoqueTIME COMPLETED:
12:15 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) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Administrator (ADM) Lerma Espiritu. Later came the Licensees Percival Roque and Felina Roque.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizer was present. LPA was temperature checked before entering the facility. LPA toured the facility with ADM.

The facility was observed to be in sanitary condition.

All restrooms observed to be adequately stocked with paper towels and hand soap.

A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file.

LPA reviewed the current Provider information Notices and current recommendation of COVID-19 prevention controls.

An advisory note was issued. See LIC 9102.

No deficiency cited during visit.

This report was reviewed with Licensee Felina Roque and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1