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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 057005020
Report Date: 10/10/2025
Date Signed: 10/10/2025 02:50:12 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
08/22/2025 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20250822105628
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: 6DATE:
10/10/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mary JaneTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not store food properly
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced on 10/10/25 at 1:15pm to conduct at complaint investigation into the allegations above. LPA met with staff Mary Jane Andres and explained the purpose of the visit, and then administrator Dorris Woodruff by phone.

The LPA investigated the allegations by physical inspection and observed a box of kirkland eggs stored out of refridgeration with the dried/canned goods in the garage. Kirkland eggs are recommended to be stored refridgerated on the box they come in. LPA asked the eggs to be disposed of immediatlely as part of the Plan of Correction.

Based on LPAs observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations is being cited on the attached LIC 9099D.

A copy of the report was read and given to staff, appeal rights were given, an exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
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 3
Control Number 27-AS-20250822105628
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: 10/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2025
Section Cited
CCR
80076(a)(14)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (14) All foods or beverages capable of supporting...progressive growth of microorganisms which can cause food infections... shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less.
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Destroy the eggs immediately, and the Licensee should read 80076 in full and send a signed affidavit of understanding to the LPA by 10/13/25.
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This requirement was not met as evidenced by: The LPA's observation of half a box of kirkland eggs being stored in an open container outside of refrigeration. air temperature reads 71*f,
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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: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3