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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 07/19/2022
Date Signed: 07/20/2022 02:42:02 PM

Document Has Been Signed on 07/20/2022 02:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Karen Puente, AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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On 07/19/2022 at 1:50 pm, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with House Manager, Maria Beasley and explained the purpose of today’s inspection. LPA later met with Administrator, Karen Puente. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. LPA observed no bodies of water. A comfortable temperature for clients is maintained at 75 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109.8 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detector and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on January 20, 2022. First aid kit was observed to be complete. Fire drill was last conducted on 07/08/2022. LPA reviewed 3 client files and 3 staff files.

- Based on record review, Client #2 (C2) and Client #3 (C3) physician's report states clients are bedridden. Based on license, the facility is licensed for 6 non-ambulatory clients. CIVIL PENALTY ASSESSED.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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 07/20/2022 02:42 PM - It Cannot Be Edited


Created By: Treana White On 07/19/2022 at 03:10 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ST. ANDREWS MANOR
FACILITY NUMBER: 057005020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) 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 and record review, the licensee did not comply with the section cited above in 80020(a). LPA observed 2 of 4 clients medical assessment is marked as bedridden. Based on license, facility is licensed to serve non-ambulatory clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Administrator agreed to update clients physician's report and submit proof to CCLD by POC date.

CIVIL PENALTY ASSESSED
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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


LIC809 (FAS) - (06/04)
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