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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 11/16/2022
Date Signed: 11/17/2022 07:44:21 AM

Document Has Been Signed on 11/17/2022 07:44 AM - 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: 3DATE:
11/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Maria Beasley - House ManagerTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Case Management Visit - Incident. LPA explained purpose of visit to house manager.

LPA discussed incident regarding R1 on telephone with licensee and house manager.

LPA asked licensee if behavioral plan for R1 has been reviewed and discussed with Valley Mountain Regional Center (VMRC) service coordinator. There is a meeting on 11/17/22 with VMRC staff to discuss a plan. Licensee will report plan of action after meeting to LPA.

No deficiencies were observed or cited from the California Code of Regulations, Title 22.

Exit interview conducted with house manager and a copy of report was left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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