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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005282
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:56:09 AM


Document Has Been Signed on 07/11/2024 11:56 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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: 5DATE:
07/11/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Victoria ValenciaTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the visit, LPA toured the facility and observed lunch being served. LPA observed a green salad, tuna casserole and garlic bread. LPA observed the food supply. There is ample fresh foods including varying vegetables, apples, bananas, watermelon and oranges. Facility indicates roughly following the menu and LPA observed ingredients matching the menu items. Facility documents what Resident 1 (R1) eats for each meal and LPA observed the documentation which indicated balanced meals. Resident 1 is not present during today's visit.

During the visit, LPA consulted with Administrator regarding food choices and resident personal rights regarding food choices.







Exit interview conducted and a copy of this report will be emailed to Administrator..
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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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