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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 05/28/2022
Date Signed: 05/28/2022 06:25:03 PM

Document Has Been Signed on 05/28/2022 06:25 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:
05/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Shea DuffeyTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maja Jensen arrived at above facility at approximately 4:00pm on 5/28/22 to deliver complaint findings. LPA met with acting Administrator Shea Duffey.

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. During the course of the investigation LPA Jensen determined a reporting deficiency had occurred.

Per California Code of Regulations, Title 22, deficiencies are being cited on the attached
809D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2022 06:25 PM - It Cannot Be Edited


Created By: Maja Jensen On 05/28/2022 at 01:44 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: 05/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2022
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements:
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

(1) Events reported shall include the following:
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement was not met as evidenced by:
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Licensee and Administrators agrees to read the regulation and send acknowledgment to CCL by email to maja.jensen@dss.ca.gov by 6/7/22
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Based on interviews and a record review of staff communications it was determined that a medication error occured on or around 4/3/22-4/4/22 and was not reported to CCL. This poses a potential health and safety 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2022


LIC809 (FAS) - (06/04)
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