306005282-1-13-2025-22-AS-FARS-DCW39N-20250113170326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005282
Report Date: 01/13/2025
Date Signed: 01/13/2025 05:03:39 PM

Document Has Been Signed on 01/13/2025 05:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ST ANDREW'S HOME FOR THE AGED 2		FACILITY NUMBER:	306005282
ADMINISTRATOR/ DIRECTOR:	VALENCIA, VICTORIA		FACILITY TYPE:	740
ADDRESS:	8681 ST ANDREWS AVE		TELEPHONE:	(714) 892-5121
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:35 PM
MET WITH:	Victoria Valencia		TIME VISIT/ INSPECTION COMPLETED:	05:17 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day Licensing Program Analysts (LPAs) Michael Tea and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 4 ambulatory and 2 non-ambulatory residents. The home currently has 4 residents. Administrator (AD) Victoria Valencia arrived shortly to conduct facility tour. AD Valencia has a valid certificate that expires on 6/30/2025. AD provided updated liability insurance that expires on 6/29/2025. LPAs along with Administrator Valencia toured the facility at 2:50 PM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 3 resident bedrooms, 2 staff bedrooms, living room, dining room, and kitchen as well as 3 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 113.7 degrees F and 114 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 12/16/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, games and community outings. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPAs observed the emergency food and water supply. LPAs reviewed four resident files and three staff files. CONTINUED ON LIC 809C DATED 1/13/2025

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 01/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST ANDREW'S HOME FOR THE AGED 2	FACILITY NUMBER: 306005282
	VISIT DATE: 01/13/2025

NARRATIVE

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All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred Arias	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/13/2025 05:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST ANDREW'S HOME FOR THE AGED 2	FACILITY NUMBER: 306005282
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation by LPAs, The kitchen stove burners are not fully operational which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Administrator to submit photos of a replacement stove along with purchase receipt.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 01/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

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