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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 057005020
Report Date: 05/01/2024
Date Signed: 05/01/2024 12:24:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240304114818
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: 4DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mable VlavianosTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff abandoned resident at hospital .
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver complaint investigation findings. LPA explained the purpose of the visit and was met by staff.

On 03/25/24 and 05/01/24 LPA Lewis visited the facility and conducted interviews with staff, interviews with residents and documentation reviews that included chart notes and medical files. According to medical file reviews, chart note reviews and physician order reports, as well as R1. R1 was not admitted into the hospital and interview with S1 they state they left the hospital at 3:00 AM.

Based on interviews and record reviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview and copie of report and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 2
Control Number 27-AS-20240304114818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/05/2024
Section Cited
CCR
85078(a)(1)
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85078 - Responsibility for Providing Care and Supervision
a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This is evedinced by:
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POC was corrected per orginal document.
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R1 was left at the hospital with no facility staff form 3-5AM, and there was not staff present at the time to care for the resident. This poses an immitate health, safety, and personal rights 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: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2