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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 05/26/2022
Date Signed: 05/28/2022 06:30:58 PM

Document Has Been Signed on 05/28/2022 06:30 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, 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: 4DATE:
05/26/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shea DuffeyTIME COMPLETED:
02:30 PM
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A virtual informal office meeting was conducted on 5/26/22 with CCL ASCP Regional Office Sacramento South and Valley Mountain Regional Center.

The purpose of this meeting was to discuss the request of a hospice waiver and underage staff working at the facility.

Present at the meeting were Licensing Program Manager (LPM) Liza King and Licensing Program Analyst Maja Jensen, St. Andrews Manor facility Administrator/Owner Doris Woodruff, Valley Mountain Regional Representatives Debra Schiffilea, Stephanie Medina, Josie Craig, Brian Bennett and Katina Richison.

LPM Liza King advised Administrator/Owner Doris Woodruff that Community Care Licensing Department (CCL) was unwilling to approve a hospice waiver unless the facility agreed to remain in compliance with all regulatory requirements associated with retaining hospice clients. In addition CCL has been made aware that underage staff are employed at the facility. LPA Maja Jensen clarified that CCL does not allow for staff under the age of 18, no exceptions.

No deficiencies were cited as a result of this office meeting. Licensing Program Analyst (LPA) Maja Jensen delivered the office report on 5/28/22 during the course of a site visit conducted for the purpose of delivering complaint findings. A copy of this report was given to acting Administrator Shea Duffey.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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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