306005403-11-24-2025-22-AS-SHAN-DNQMW9-20251124085759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005403
Report Date: 11/24/2025
Date Signed: 11/24/2025 08:58:51 AM

Document Has Been Signed on 11/24/2025 08:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ST. ANDREWS HOME FOR THE AGED		FACILITY NUMBER:	306005403
ADMINISTRATOR/ DIRECTOR:	VALENCIA, VICTORIA		FACILITY TYPE:	740
ADDRESS:	8791 ST. ANDREWS AVENUE		TELEPHONE:	(714) 496-8302
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 6		CENSUS: 6	DATE:	11/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:27 AM
MET WITH:	Victoria Valencia		TIME VISIT/ INSPECTION COMPLETED:	12:15 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	Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced visit to the facility for the purpose of completing the required annual inspection. Upon arrival, LPA Haddadin was greeted and granted entry by Victoria Valencia, Administrator. LPA explained the nature of the visit, and the Administrator accompanied LPA during the inspection. At the time of the visit, there were six residents in care, and no residents were receiving hospice services. LPA toured the interior and exterior of the facility with the Administrator. Required Department postings were observed throughout the facility, and the facility was operating within its licensed capacity. A minimum of one week of nonperishable food and at least two days of perishable food were available, with additional storage in a spare refrigerator and freezer located in the garage. The facility was maintained at a comfortable temperature. Medication was inspected and observed to be centrally stored in a locked storage cabinet located in the kitchen. Medications were properly labeled and stored inaccessible to residents in care. Bathrooms were inspected, and the hot water temperature measured 112.2 degrees Fahrenheit. Bathrooms contained an adequate supply of soap, toilet paper, and towels, and were equipped with required safety measures, including non-skid mats and grab bars. Lighting throughout the facility was sufficient to support resident safety and comfort.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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. ANDREWS HOME FOR THE AGED	FACILITY NUMBER: 306005403
	VISIT DATE: 11/24/2025

NARRATIVE

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The facility had adequate hand hygiene, cleaning, and disinfecting supplies, and toxic chemicals, cleaning solutions, and disinfectants were stored locked under the kitchen sink and in a locked storage cabinet in the garage. Clean linens were available and properly maintained. Residents’ bedrooms were inspected and observed to have sufficient lighting, required furnishings, and all required components. Adequate storage space was provided for each resident. Smoke detectors were tested and found to be operational. During the exterior inspection, outdoor passageways were observed to be free of obstructions, and shaded seating areas were available for resident use and enjoyment. Fire extinguishers were observed throughout the facility with a service date of June 26, 2025. The facility has a second floor; however, no residents reside on that level, and LPA verified that residents in care do not have access to the second floor. LPA verified that fire drills are conducted as required and confirmed the most recent fire drill was completed on October 30, 2025. LPA reviewed five resident records, and all required documentation was present and current. LPA also reviewed three employee records and verified that all employees had criminal record clearances, were associated to the facility, and maintained current First Aid certifications. Based on observations and records reviewed during today’s inspection, no deficiencies were noted in the areas inspected in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with the Administrator, and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025

LIC809 (FAS) - (06/04)

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