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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 06:29:05 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
05/27/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220527165904
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:
05:00 PM
MET WITH:Shea DuffeyTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Underage staff working at facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On Saturday 5/28/22 Licensing Program Analyst ( LPA ) Maja Jensen arrived at facility unannounced to open a complaint investigation for the above allegation.

LPA Jensen investigated the same complaint allegation under complaint number 27-AS-20220426123415.

During the course of the investigation for complaint 27-AS-20220426123415. 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 administrators and 1 client.

Based on preponderance of evidence the allegation is SUBSTANTIATED. There are no deficiencies cited under this complaint. Per the California Code of Regulations, Title 22, deficiencies were observed and cited under complaint # 27-AS-20220426123415.
An exit interview was conducted and the report accompanied by the appeals rights was given.
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)
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