057005020-6-22-2023-27-AS-RCAL-CT2U6T-20230622151853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:22:57 PM

Document Has Been Signed on 06/22/2023 03:22 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ST. ANDREWS MANOR		FACILITY NUMBER:	057005020
ADMINISTRATOR:	DORIS D. WOODRUFF		FACILITY TYPE:	735
ADDRESS:	36 ST. ANDREWS ROAD		TELEPHONE:	(209) 483-8725
CITY:	VALLEY SPRINGS	STATE: CA	ZIP CODE:	95252
CAPACITY: 6		CENSUS: 0	DATE:	06/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Doris Woodruff, Administrator		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/22/23, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility at approximately 7 am and met with the Administrator, Doris Woodruff. The facility had been empty of residents due to damage from a storm and needed repairs. No other staff had been hired and no residents were present. The LPA stated the purpose of the visit and began a tour of the facility beginning with the laundry room. LPA Campbell observed a staff bathroom and garage door. The bathroom contained only a sink and toilet that were free of stains or odors. In the garage, there were entries for a private residence for one staff or a married couple and a sleeping room for staff who lived far away. It contained bunk beds arranged to contain three beds. The administrator then directed LPA to the kitchen. Cleaning agents were under the sink in the kitchen and in the laundry room. Both locations were under lock and key or magnetic locks. Administrator Doris Woodruff showed the facilities first aid kits as well. One kit had tweezers, scissors, and manual. There were two medication cabinets. One cabinet located in the living room would be the main cabinet for dispersal. The other cabinet in the dining room was too be used for spillover storage of medications. On the far side of the dining room is an office and a common area used for TV and other activities. A shelf contained a variety of facility binders. No binders containing personal information were left unlocked. There were no obstructed passageways in hallways or other rooms. Activity items were stored in a cabinet and there was a calendar of activities for the residents. Bedrooms examined contained a dresser, closet and bed with covers and mattress as well as a night stand. Drawers were randomly pulled and examined. There were four single bedrooms and one double bedroom for residents. The double bedroom had doors leading to the backyard. Two bathrooms were available for residents. In all there were seven bedrooms and three bathrooms. LPA and administrator viewed the backyard which faced a golf course. There was a protective netting to prevent golf balls from hitting the house. The net covered the full width of the backyard and house.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ST. ANDREWS MANOR	FACILITY NUMBER: 057005020
	VISIT DATE: 06/22/2023

NARRATIVE

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Upon review of the staff bedrooms in the garage, it was decided that a new fire inspection was required because the facility sketch does not show the staff bedrooms. At 9:00 am, VMRC Community Services Liasion, Stephanie Medina arrived to tour the updated facility and discussed, dual vendorization and prior facility damage. LPA Campbell then measured the hot water at 105 degrees Fahrenheit. Administrator reported that she would be out of the country from June 26th to July 3rd;.

Updated copies of the following documents were requested for the facility file and are to be submitted to CCL by 06/26/23:

LIC 308 Designation of Administrative Responsibility
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate.
Updated Facility Sketch

The administrator will also schedule the full fire inspection by 06/26/23 and notifiy LPA Campbell of the date. The LPA sent the fire inspection request during today's inspection as well due to time limitations.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 03:22 PM - It Cannot Be Edited

Created By: Renee Campbell On 06/22/2023 at 09:26 AM

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: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/26/2023 Section Cited CCR 80022(b)(7)	1 2 3 4 5 6 7	(a) Each licensee shall have..a.. definitive plan of operation. (b) The plan shall contain the following: (7)A sketch of the building(s)..a floor plan which describes .. uses intended, room dimensions, and a designation of the rooms. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit an updated facility sketch showing the new room additions during today's inspection and have a new Fire Inspection scheduled by 06/26/2023.
	8 9 10 11 12 13 14	Based on record review, the facility did not match the facility sketch on file.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Emerita Curiel

LICENSING EVALUATOR NAME:

Renee Campbell

LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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