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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 057005020
Report Date: 05/28/2022
Date Signed: 05/28/2022 06:33:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220426123415
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:
05/28/2022
UNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Shea DuffeyTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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9
Staff did not treat resident with respect
Facility personnel staff are under age
Residents do not receive proper medication assistance
Staff's medication is accessible to residents in care
INVESTIGATION FINDINGS:
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On Saturday 5/28/22 LPA Jensen arrived at facility unannounced to continue the complaint investigation for complaint # 27-AS-20220426123415.

During the course of the investigation, LPA Jensen conducted site visits on 5/3/22 and 5/28/22. LPA Jensen reviewed records including but not limited to client files, staff roster, staff schedules, text messages and photographs. LPA Jensen also conducted interviews with 4 staff members, two adminstrators and 1 client.

Staff did not treat resident with respect:
Based on interviews conducted the Administrator acknowledged an incident occurred wherein a staff member was startled by a client's involuntary actions and used an inappropriate tone which resulted in the staff member being counseled. The staff member likewise acknowledged the incident. Due to the preponderance of evidence this allegation is found to be SUBSTANTIATED.
Continued on 9099C.....

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20220426123415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 057005020
VISIT DATE: 05/28/2022
NARRATIVE
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Facility Personnel Staff are Underage:
Based on interviews with two Administrators there are underage staff working at the facility. A review of the staff roster and schedules also confirm there are underage staff working at the facility. A unannounced facility visit conducted by representatives from the Valley Mountain Regional Center on 5/27/22 also confirmed under aged staff working at the facility. Based on a preponderance of evidence this allegation SUBSTANTIATED.

Residents do not receive proper medication assistance:
Based on interviews conducted with staff and review of staff communications a medication error occurred with medication for Resident 1 (R1) between 4/3/22 and 4/4/22. Based on a preponderance of evidence this allegation is SUBSTANTIATED.

Staffs medication is accessible to residents:
Based on interviews conducted with staff and review of staff communications a bottle of OTC medication that is not prescribed to a resident care was found left on the counter around or shortly before April 7, 2022. Based on a preponderance of evidence this allegation SUBSTANTIATED.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 the following deficiencies were observed (see LIC 9099-D) were cited. Failure to correct the deficiency may result in civil penalties. An exit interview was conducted and the report accompanied by the appeals rights was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20220426123415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 057005020
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2022
Section Cited
CCR
80072(a)(1)
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7
Personal Rights:
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
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The Licensee agrees to provide training, counseling and disciplinary action if appropriate if it is learned that any staff member treats a resident inappropriately. The staff member who acted in violation of this regulation related to the investigation complaint has been counseled and has had no infractions since counseling therefore no plan or correction is required at this time.
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Based on interviews with staff and the Administrator a staff member reactedand spoke to a resident inappropriately as a result of being started by that resident's involuntary action. This poses a potential risk to the resident's personal rights.
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Type B
05/28/2022
Section Cited
CCR
80065(d)(1)-(2)
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Personnel Requirements:
(d) The following facility personnel staff shall be at least 18 years of age:

(1) Persons who supervise employees and/or volunteers.

(2) Persons, including volunteers, who provide any element of care and supervision to clients.

This requirement was not met as evidenced by:
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The Licensee agrees to terminate underage staff as of this date and submit copies of written notification of termination given to underage staff members to CCL by 5/31/22. The Licensee agrees to submit to CCL by email to maja.jensen@dss.ca.gov, a written agreement that the facility will not employee under age staff by 5/31/22
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Based on interviews with two Administrators and a review of a staff roster and schedules the licensee has employed staff that is under the age of 18. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 27-AS-20220426123415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 057005020
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2022
Section Cited
CCR
80092.10
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7
80092.10 Gastrostomy Feeding, Hydration, And Care
a) A licensee of an adult CCF may accept or retain a client who requires gastrostomy care, feeding, and/or hydration if all of the following conditions are met:
(4) The licensee ensures that gastrostomy feeding, hydration, medication administration through the gastrostomy, and stoma cleaning are provided by a licensed professional when the client is unable to provide his/her own feeding, hydration and care.
This requirement was not met as evidenced by:
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Licensee agrees to conduct staff training on medication administration and provide acknowledgement to CCL by email to maja.jensen@dss.ca.gov by 6/7/22
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Based on interviews and record reviews of staff communications R1's medication were found on the floor underneath his bed which is evidence that R!'s required medication dosage was missed. This poses a potential health and safety risk to residents in care.
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Type B
05/28/2022
Section Cited
CCR
80087(a)
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Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not as evidenced by:
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Licensee agrees to conduct staff training on proper storage of hazardous materials such as personal medications and provide acknowledgement to CCL by email to maja.jensen@dss.ca.gov by 6/7/22
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Based on interviews and record reviews of staff communications staff medication was left out and accessible to residents care which creats an environment that is unsafe. This poses a potential health and safety risk to resident's in care.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220426123415

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: DATE:
05/28/2022
UNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:TIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
resident sustained unexplained injuries while in care
Disinfectants are accessible to residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On Saturday 5/28/22 LPA Jensen arrived at facility unannounced to continue the complaint investigation for complaint # 27-AS-20220426123415.

During the course of the investigation, LPA Jensen conducted site visits on 5/3/22 and 5/28/22. LPA Jensen reviewed reviewed records including but not limited to client files, staff roster, staff schedules, text messages and photographs. LPA Jensen also conducted interviews with 4 staff members, two adminstrators and 1 client.

Disinfectants are accessible to residents in care
During the course of two facility visits LPA Jensen did not witness any disinfectants accessible to residents in care. Interviews conducted with staff were conflicting.

continued.....

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20220426123415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 057005020
VISIT DATE: 05/28/2022
NARRATIVE
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The preponderance of evidence standard has not been met, therefore the above allegation is determined to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Resident sustained unexplained injuries while in care
LPA Jensen reviewed resident records, conducted interviews with 4 staff and two Administrators and one staff member. The staff interviews were conflicting.

The preponderance of evidence standard has not been met, therefore the above allegation is determined to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, no deficiencies are being cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6