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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 01/20/2023
Date Signed: 01/25/2023 04:48:42 PM

Document Has Been Signed on 01/25/2023 04:48 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:
01/20/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator and LicensseeTIME COMPLETED:
09:00 AM
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Late entry: On 01/20/23 the RO met via Zoom. Members present included VMRC representatives Stephenie Medina, Katina Richison, and Brian Bennett. From the RO Liza King, LPM was present and facility representatives included the licensee Doris Woodruff and the Administrator designee Karen Puente.
The purpose of the meeting was to follow up the events leading up to the evacuation, the relocation of the residents, and the plan moving forward.
The clients are currently in a hotel setting, the RO expressed concern with the clients access to activities and stimulation. Facility representatives assured the the clients schedule is being followed reflective of their activities at home, clients are participating in day program, outings and staff are engaged.
The Administrator has provided an updated LIC200 to the RO to process a request for a CHOL and is awaiting the FD scheduling. Updates on this inspection as well as inspections on the 36 St. Andrews location will be provided as acquired.
During the meeting the RO addressed the issue of the licensee leaving the country without notifying the RO, LPM King reminded the licensee that the RO should be notified in the future, in addition to documentation being submitted to the RO for a designee in the licensees absence. Licensse reported that she has been out of the country since January 04, 2023 and plans to return mid February. Licensee reports that business partners are providing assistance as needed to the Admin re; facility relocation spots, inspections, documentation and are always available.
LPM addressed the oversite of St. Charles and Karen Cares with the current events of St. Andrews. Admin reports given the events she has not been able to be present at all at St. Charles. Licensee will look into an Alternate Admin for the St. Charles location since Karen is currently Admin of the three locations and verbalized difficulty being onsite at all three.
The RO will continue H&S visits while clients are relocated.
No deficiencies were observed or cited from the California Code of Regulations, Title 22.

Exit interview conducted with the Admin and a copy of report was emailed, return signature requested.
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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