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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005282
Report Date: 10/09/2023
Date Signed: 10/09/2023 10:17:33 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20231004084153
FACILITY NAME:ST ANDREW'S HOME FOR THE AGED 2FACILITY NUMBER:
306005282
ADMINISTRATOR:VALENCIA, VICTORIAFACILITY TYPE:
740
ADDRESS:8681 ST ANDREWS AVETELEPHONE:
(714) 892-5121
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 4DATE:
10/09/2023
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Emily Galang and Victoria ValenciaTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Staff are not serving residents nutritious quality meals while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Victoria Valencia arrived during the visit.

During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as Individual Program Plan and physician orders. Regarding the allegation that staff are not serving residents nutritious quality meals while in care, the investigation revealed the following: LPA observed facility food supply during the visit. LPA observed ample fresh food supply including lean meats such as turkey and chicken, grapes, papaya, watermelon, lettuce, tomato, cabbage, strawberries and potatoes. LPA observed the facility menu and staff indicate following the menu daily. The menu included healthy options and three out of three residents verified eating the corresponding breakfast for today's date. Resident 1 (R1) confirmed meals with LPA as well as physician prescribed protein drinks. Due to conflicting information, CONTINUED ON LIC 9099C DATED 10/09/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20231004084153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ST ANDREW'S HOME FOR THE AGED 2
FACILITY NUMBER: 306005282
VISIT DATE: 10/09/2023
NARRATIVE
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LPA is unable to corroborate allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2