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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057005020
Report Date: 01/24/2023
Date Signed: 01/25/2023 04:47:07 PM

Document Has Been Signed on 01/25/2023 04:47 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:
01/24/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee Dorris Woodfuff and Admin TIME COMPLETED:
05:00 PM
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 On 01/24/23 the RO met via Zoom. Members present included VMRC representatives Stephenie Medina and Katina Richison. From the RO Stephenie Doub, Regional Manager and Liza King, LPM were 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 relocation of the residents, and the plan moving forward.
Earlier in the day the RO was notified that the facility representatives no longer wish to move forward with a CHOL application. Licensee reported during this meeting that modification to the existing structures were not feasible. The current relocation site is reserved until 01/27/23. The RO requested a plan through next week to be provided by end of day 01/25/23. Relocation of clients to temporary placement's were discussed and the Admin will follow up with VMRC for next steps.
Oversite of St. Charles was discussed, Licensee will create a plan for an alternative designee to be present at St. Charles 20hours a week. All required documents to associate will be provided to the RO, LPM will follow up by eod 01/26/23.
The RO will continue H&S visits.

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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