<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002669
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:23:18 PM

Document Has Been Signed on 03/14/2024 01:23 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SHERWOOD FOREST MANORFACILITY NUMBER:
507002669
ADMINISTRATOR:RONALDO DATOFACILITY TYPE:
735
ADDRESS:509 EAST RUMBLE ROADTELEPHONE:
(209) 342-0660
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 4DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Ronaldo Dato TIME COMPLETED:
01:45 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) Jason Lund arrived unannounced to conduct an Annual/Required inspection. LPA Lund met with Administrator Ronaldo Dato and explained the reason for the visit. Census: 4

LPA Jason Lund and Administrator Ronaldo Dato toured/inspected the facility. LPA Lund inspected the care home to ensure compliance with Title 22 regulations. There are three bedrooms and two bathrooms for resident’s use. In addition, there are three staff rooms and two staff bathrooms in the home. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to residents. LPA inspected the backyard and perimeter of the care home and observed all storage sheds to be locked and secured, and there appeared to be no potential safety hazards to the residents. Smoke detectors are hard wired and operational and care home also has a carbon monoxide detector. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA Lund reviewed two staff & two clients files and were in compliance.

No deficiencies were cited during visit. Exit interview held and copy left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 1