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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
057005020
Report Date:
09/04/2024
Date Signed:
09/04/2024 11:27:50 AM
Document Has Been Signed on
09/04/2024 11:27 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 MANOR
FACILITY NUMBER:
057005020
ADMINISTRATOR/
DIRECTOR:
DORIS D. WOODRUFF
FACILITY TYPE:
735
ADDRESS:
36 ST. ANDREWS ROAD
TELEPHONE:
(209) 483-8725
CITY:
VALLEY SPRINGS
STATE:
CA
ZIP CODE:
95252
CAPACITY:
6
CENSUS:
DATE:
09/04/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:
Maria Beasley
TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility announced for the purpose of amending a citation dated 05/01/2024. LPA explained purpose of visit to the to staff.
The citation issued on 5/1/24 is being amended from 80078(a)(1) to 85078(a)(1).
Do Decencies are being cited during todays case management visit.
Exit interview and copy of report given. Appeal rights provided.
SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Kesha Lewis
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/04/2024
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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