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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 01/17/2023
Date Signed: 01/17/2023 06:46:56 PM

Document Has Been Signed on 01/17/2023 06:46 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:KAREN PUENTEFACILITY TYPE:
735
ADDRESS:36 ST. ANDREWS ROADTELEPHONE:
(209) 920-3462
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 6CENSUS: 4DATE:
01/17/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Anna BisbyTIME COMPLETED:
07:00 PM
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On 1/17/23 at approximately 5:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at 2323 Grand Canal Ave in Stockton, California to conduct a health and safety check. The facility was evacuated due to the winter storm 22/23 and the residents are currently being housed at the Hilton Hotel. LPA Jensen met with care provider Anna Bixby and explained the purpose of today's visit.

The facility has secured 2 ADA hotel rooms. The current census is 4. There are 2 residents being housed in each room. Each room is equipped with 2 queen beds, night stands, dressers and mini refrigerator. Each room was observed to have beverages and snacks on hand. LPA Jensen interacted with 2 of 4 residents. The residents appeared content and stated they are getting adequate food. The Licensee purchased dinner from a local restaurant for the residents on this date. LPA Jensen observed the rooms to have an adequate supply of incontinence care and first aid supplies on hand. LPA Jensen observed the medications to be locked in a storage container. LPA Jensen reviewed the Medication Administration Record for 4 of 4 residents and determined them to be complete and consistent with the medication on hand.

Upon arrival, LPA Jensen observed all residents to be in one room. 3 of 4 residents were watching a movie and 1 of 4 residents was asleep. LPA Jensen spoke to a staff member that had just woken up from a nap in the room that was not being used as that staff member works the night shift. LPA Jensen called the Administrator and spoke to Karen Puente. She stated that the residents continue to participate in day program and all gather in room to do so. While in day program, the Administrator advised her night staff they may rest if needed however residents can still return to their rooms whenever they wish to do so. LPA Jensen recommended securing another room for staff to sleep. LPA Jensen called Licensee and spoke to Doris Woodruff and explained her concerns related to staff needing access to a room for sleeping. Licensee Doris Woodruff agreed to take action to ensure that staff and residents are not utilizing the same sleeping areas.

No citations are being issued as a result of this visit. An exit interview was conducted and a copy of this report was left with care staff at the hotel.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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