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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 11:43:37 AM

Unsubstantiated


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
03/18/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240318153415
FACILITY NAME:ST. ANDREWS MANORFACILITY NUMBER:
057005020
ADMINISTRATOR:DORIS D. WOODRUFFFACILITY TYPE:
735
ADDRESS:36 ST. ANDREWS ROADTELEPHONE:
(209) 483-8725
CITY:VALLEY SPRINGSSTATE: ZIP CODE:
95252
CAPACITY:6CENSUS: 4DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mable VlavianosTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights
Physical abuse
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.

The investigation was conducted by LPA Lewis. The investigation consisted of LPA facility observations, interviews with staff, interviews with residents and review of resident files, resident medical files, and chart notes. On 3/13/2024, 03/25/2024 and 05/01/2024 LPA Lewis visited the facility and conducted interviews with staff, interviews with residents and documentation reviews. Based on LPAs observations and interviews which were conducted S1-S4 accounts of the facility were consistant and R2 and not experinedced or seen any consurns. The preponderance of evidence standard has not been met, therefore, the Department has determined the the alleagations to be UNSUBSTANTIATED. A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

Exit interview and a copy of the report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
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)
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