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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:16:01 PM

Document Has Been Signed on 06/22/2023 03:16 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ST. ANDREWS MANORFACILITY NUMBER:
057005020
ADMINISTRATOR:DORIS D. WOODRUFFFACILITY TYPE:
735
ADDRESS:36 ST. ANDREWS ROADTELEPHONE:
(209) 483-8725
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 6CENSUS: DATE:
06/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Doris WoodruffTIME COMPLETED:
11:30 AM
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On 06/22/23 at approximately 10:00 AM, LPA Campbell conducted a Case Management Health Check at 36 St.Andrews Road in Valley Springs. The LPA met with Doris Woodruff, the Administrator, regarding mold eradication due to water intrusion.

Because of the possibility of the mold, no residents or staff are in the facility.

Upon review of facility, no evidence of mold was found. A report completed by the mold inspector was received and reviewed as well. The facility was found to be safe from mold exposure.

An exit interview was held, and a copy of the report will be provided to Administrator Doris Woodruff.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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