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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208826
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:50:13 PM

Document Has Been Signed on 12/16/2024 12:50 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SHERWOOD ELDERLY CARE FACILITYFACILITY NUMBER:
157208826
ADMINISTRATOR/
DIRECTOR:
BARAJAS, JUDITHFACILITY TYPE:
740
ADDRESS:2204 SHERWOOD AVETELEPHONE:
(661) 220-6647
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93304
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Administrator Judith BarajasTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA explained the purpose of the visit and met with Administrator Judith Barajas.

A tour of the facility was conducted with the Administrator. The residence was set at 72 F temperature and free of passageway obstructions inside and outside.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication cart in the kitchen. Cleaning supplies were locked in a cabinet under the kitchen sink. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguisher was last serviced 11/27/24. LPA checked water temperature which measured at 114.5 F. Fire drill was last conducted 12/1/24.

Resident, medication and staff records were reviewed. R2 missed evening medications on 12/13/24. LPA did not locate any notes as to why the evening medications were not administered to R2. R2 did not have a home health care plan or any information as to how often Home Health is coming to the facility to care for R2's condition. Current first aid and CPR were reviewed.

A copy of this report with appeal rights and plan of correction was provided to the Administrator.

Sergiy PidgirnyTELEPHONE: (559) 246-0610
Shawna DoucetteTELEPHONE: (559) 580-4595
DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SHERWOOD ELDERLY CARE FACILITY

FACILITY NUMBER: 157208826

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not administer or have any notes as to why R2's PM medications were not administered on 12/13/24 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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3
4
Licensee agrees to conduct a medication training and submit date training will be conducted by POC due date 12/17/24
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Sergiy PidgirnyTELEPHONE: (559) 246-0610
Shawna DoucetteTELEPHONE: (559) 580-4595

DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024

LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SHERWOOD ELDERLY CARE FACILITY

FACILITY NUMBER: 157208826

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not administer or have any notes as to why R2's PM medications were not administered on 12/13/24 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
1
2
3
4
Licensee agrees to conduct a medication training and submit date training will be conducted by POC due date 12/17/24
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.
Sergiy PidgirnyTELEPHONE: (559) 246-0610
Shawna DoucetteTELEPHONE: (559) 580-4595

DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024

LIC809 (FAS) - (06/04)
Page: 2 of 6