507002669-3-30-2026-27-AS-NWPN-DSNM5L-20260330091830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507002669
Report Date: 03/24/2026
Date Signed: 03/30/2026 09:18:55 AM

Document Has Been Signed on 03/30/2026 09:18 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	SHERWOOD FOREST MANOR		FACILITY NUMBER:	507002669
ADMINISTRATOR/ DIRECTOR:	RONALDO DATO		FACILITY TYPE:	735
ADDRESS:	509 EAST RUMBLE ROAD		TELEPHONE:	(209) 342-0660
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY: 6		CENSUS: 4	DATE:	03/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Ron Dato		TIME VISIT/ INSPECTION COMPLETED:	04:30 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, Noel Wolf Petersen, arrived unannounced to the facility to conduct an annual inspection. LPA met with administrator Ron Dato to explain the purpose of the visit. Physical inspection included but was not limited to the bedrooms, bathrooms, kitchen, common areas, exterior, and evacuation routes. Bedrooms have adequate furniture and furnishings, to include mattress encasements. Bathrooms have functional hardware, and water measured between 105-120*f. Kitchen has adequate lockable storage for sharps, medication, and toxics. Kitchen has adequate food and food storage for 2 days perishable, 7 days nonperishable, and 3 days emergency. Exterior and common areas have furnishings in good repair and are free of trip hazards. Evacuation route gate is not able to latch by itself into the gate post, Owner CJ took care of it. Medication was checked for 2 clients at random, found to be in accordance with mars, no concerns about how to document drug dispersal. A medication crushing tool was observed packed in with a residents medication, the administrator was able to provide a puree order for food, but not a physicians order for the crushed medication and a written consent signed by the responsible party/self responsible adult indicating knowlege and consent to have medications crushed/cammoflauged. LPA is asking the facility to update the 602, with a physicians order to crush medication or else discontinue crushing medications. Continued on C page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERWOOD FOREST MANOR	FACILITY NUMBER: 507002669
	VISIT DATE: 03/24/2026

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Review of client files had some missing elements: exception letters regarding Colonestemy, PEG tube, and Incontinence Care, O2 administration. The residents who have the care are possibly excepted, LPA is asking the Administrator to locate that paperwork and sending it to the LPA. Barring finding the exception paperwork, the Licensee should submit a exception letter asking for an exception for each type of restricted care per resident, a 602 for the residents involved, updates to the plan of operation(regarding staff training/common considerations). One client has been freshly diagnosed with a need for catheter care and there is not a possibility of finding an old exception letter, and the Licensee will begin exception process for that particular restricted care.

interviewed 2 clients, 2 staff.

Review of staff files had all the documents present and up to date. staff trainings, continued and initial, cpr/first aid training's, health screening, and criminal record clearance.

Administrator files were reviewed including the infection control plan, facility sketch with evacuation route, required posters, Liability insurance/workers comp, and administrators certificate. Present and up to date.

the evacuation control plan, LIC 610d/e was unfilled out, should be completed and sent to the LPA, (noel.wolfpetersen@dss.ca.gov).

No citations issued, the care has been provided for many years in the case of most of these restricted condition clients, and the administrator is comfortable taking steps to get the facility in order. LPA gave guidance to the facility that before accepting or retaining a resident who is meeting restricted care conditions, Licensing should be notified and the exception process should begin so that the residents needs can be enshrined in the facility plan of op.

A copy of the report was given to the he administrator, exit interview was conducted

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

LIC809 (FAS) - (06/04)

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