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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:40:31 AM

Document Has Been Signed on 06/20/2024 11:40 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ST. ANDREWS MANORFACILITY NUMBER:
057005020
ADMINISTRATOR/
DIRECTOR:		DORIS D. WOODRUFFFACILITY TYPE:
735
ADDRESS:36 ST. ANDREWS ROADTELEPHONE:
(209) 483-8725
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 6CENSUS: 4DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:21 AM
MET WITH:Shirley Yudence TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 01/20/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Shirley Tudence and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. There are currently 4 residents who reside at this facility. The LPA Martinez toured the facility with Shirley Tuvedence on 06/20/2024 at 10:00 AM.

LPA Martinez reviewed two client files and two staff files, which files were maintained. The facility has an infection control plan and natural disaster plan. LPA Martinez requested a copy of liability insurance and surety bond. Facility staff agreed to email documents by 06/24/2024 by 5:00 PM. The facility Last fire drill was on May 10, 2024. LPA Martinez reviewed two medication administration records (MAR), and the records were maintained. The facility has a first aid kit. LPA Martinez reviewed two PNI ledgers, and both ledgers were maintained. The facility water temperature measured at 108 degrees, and the facility temperature measured at 75 degrees. The facility has an adequate food supply, and the kitchen was sanitary. Client bedrooms, bathrooms, common areas were furnished and sanitary. The facility fire extinguisher tags were not maintained, and LPA requested a fire inspection report. Facility staff were not able to provide documentation during the annual inspection visit. The fire extinguisher tag located at the kitchen indicated the last inspection was on December 22, 2022. In addition, the fire extinguisher located in the garage did not have an inspection date on the inspection tag. The fire inspection tag also reported the manufacture date was 2023. LPA Martinez reviewed the back side of the kitchen fire extinguisher tag, and facility staff signed off on the monthly inspection record section. The last staff fire extinguisher inspection was on June 07, 2024. However, facility staff did not have the fire extinguisher inspected by a professional fire inspection/testing company. Continued...

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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Document Has Been Signed on 06/20/2024 11:40 AM - It Cannot Be Edited


Created By: Avelina Martinez On 06/20/2024 at 10:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ST. ANDREWS MANOR
FACILITY NUMBER: 057005020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020(a) Fire Clearance: All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above in [2] out of [2] fire extinguishers were not maintained, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Facility staff agrees to have fire extinguishers serviced and tag maintained by POC date 06/21/24 by 5:00 PM. Facility staff will email service documentation by 5:00 PM 06/21/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ST. ANDREWS MANOR
FACILITY NUMBER: 057005020
VISIT DATE: 06/20/2024
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An immediate civil penalty of $500.00 shall be assessed on June 20, 2024 for not maintaining fire extinguishers. As a result of this annual inspection, the facility is not in compliance with Title 22 regulations. A deficiency can be found on the 809D page. An exit interview was conducted, and a copy of this 809 report, 809D page, and appeals rights were provided to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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