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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 10/27/2021
Date Signed: 10/27/2021 10:43:19 AM

Document Has Been Signed on 10/27/2021 10:43 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ST. ANDREWS MANORFACILITY NUMBER:
057005020
ADMINISTRATOR:WOODRUFF, DORISFACILITY TYPE:
735
ADDRESS:36 ST. ANDREWS ROADTELEPHONE:
(209) 920-3462
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 6CENSUS: 6DATE:
10/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Karen PuentiTIME COMPLETED:
10:55 AM
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On 10/27/21, Licensing Program Analyst, (LPA) Mohamed Filouane, conducted an unannounced case management visit to verify if a previously identified individual is currently working at the facility. LPA was sanitized and answered a health and safety COVID-19 questionnaire.

At approximately 10:25 AM, LPA Filouane met with Administrator Karen Puenti and explained the purpose of the visit. LPA asked the Administrator if the previously identified individual is currently working at the facility. The Administrator stated the individual is not working in the facility and has not worked in the facility for quite some time. LPA met with all the staff members in the facility and met with all the residents, who were in the middle of an activity program.

Exit interviewed conducted with the Administrator. A copy of this report will be emailed to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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