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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005403
Report Date: 10/22/2021
Date Signed: 10/22/2021 11:18:49 AM

Document Has Been Signed on 10/22/2021 11:18 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. ANDREWS HOME FOR THE AGEDFACILITY NUMBER:
306005403
ADMINISTRATOR:VALENCIA, VICTORIAFACILITY TYPE:
740
ADDRESS:8791 ST. ANDREWS AVENUETELEPHONE:
(714) 496-8302
CITY:WESTMINISTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 5DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Victoria ValenciaTIME COMPLETED:
11:30 PM
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Licensing Program Analysts (LPAs) Michelle Reed and Jerome Haley conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Mario Valencia and explained the reason for the visit. Before letting us into the facility our temps were taken and we signed into the visitors log book. Administrator Victoria Valencia arrived during the visit. Licensee Victoria Valencia has a current administrator certificate expiring on 10/31/2021.

At 10:15 AM, LPAs toured the facility with Caregiver Mario. Facility has five clients present during today's visit. LPAs observed clients relaxing in the facility watching television. LPAs spoke with two clients who appeared happy and well taken care of. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility test residents for Covid-19 every other week and documents the results. All staff and all residents are vaccinated for Covid-19. Facility has covid precaution postings as well as all required department postings. The facility mitigation plan has been reviewed, completed, and approved. LPAs observed adequate emergency food as well as an emergency kit prepared and ready to go. LPAs toured the outside grounds and observed multiple outside shaded visitation areas. Exit gates are unlocked and self latching. LPAs observed the posted activity schedule for the month.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was provided to AD Victoria Valencia.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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