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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 01/21/2023
Date Signed: 01/21/2023 02:03:52 PM

Document Has Been Signed on 01/21/2023 02:03 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:
01/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Karen PuenteTIME COMPLETED:
02:00 PM
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LPA Albert Johnson made an unannounced health and safety check. LPA met with Staff and the Administrator.

LPA was informed that the residents will be relocating to the Travel Lodge closer to the facility in Valley Springs. LPA advised the Administrator to inform the hotel that oxygen is being used in the rooms and a notice should be placed on the door and if required of the hotel to notify the local fire department.

LPA checked the rooms for medications, food/snacks and resident files. The Staff were informed that they will be at a relocation address until further notice.

The residents appear to be in good health at this time and there are no immediate safety concerns. The department will continue to monitor the situations with health and safety checks until the residents return to their residence.

Exit interview conducted with staff at the Hilton.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2023
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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