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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 01/28/2023
Date Signed: 01/31/2023 09:14:52 AM

Document Has Been Signed on 01/31/2023 09:14 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:KAREN PUENTEFACILITY TYPE:
735
ADDRESS:36 ST. ANDREWS ROADTELEPHONE:
(209) 920-3462
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 6CENSUS: 4DATE:
01/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karen Puente TIME COMPLETED:
12:00 PM
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On 1/28/2023 at 10:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to 123 Selkirk Ranch Road Angels Camp, CA 95222. LPA met with staff members, Bobby Johnson and Anna Basby who were asked to call the Facility Designated Administrator(FDA) to let her know that CCL was present at this time. LPA Pascua was able to speak to FDA Puente to explain the purpose of the visit. The purpose for this visit was to conduct a Health and Safety visit. At this time FDA Puente allowed other staff to sign for paperwork for this visit.

The physical property of the facility is undergoing maintenance due to the recent storms in the area. As a result, the residents have been relocated to a hotel.

The current census was 4. The residents have been split between two hotel rooms. At this time of the visit it was observed that all residents were in one hotel room watching tv and doing activities.
LPA Pascua conducted a tour of the hotel rooms. LPA Pascua reviewed medication and resident files. LPA Pascua observed the residents rooms to be clean and sanitary. Main area for resident use was toured and the furniture intended for resident use was observed to be in good repair at this time. LPA Pascua observed food supply to be sufficient to meet the residents needs at this time.

The residents were observed to be in good health and there are no immediate safety concerns. The department will continue to monitor the situations with health and safety checks until the residents are able to return to their primary residence.

An exit interview was conducted and copy of this report will be provided to the Facility Designated Administrator, Karen Puente.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2023
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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