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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002679
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:37:19 PM

Document Has Been Signed on 10/25/2023 02:37 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SHERWOOD FOREST MANOR 2FACILITY NUMBER:
507002679
ADMINISTRATOR:RONALDO DATOFACILITY TYPE:
740
ADDRESS:601 E. RUMBLE ROADTELEPHONE:
(209) 577-1247
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 3DATE:
10/25/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator Ronald Dato TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a proof of correction (POC) visit. LPA Lund met with Administrator Ronald Dato and explained the reason for the visit. Census 3

The facility failed to follow client's prescribed diet. The facility emailed a proof of correction to LPA Jacobs.


No deficiencies were citied during this inspection. Exit interview held with Administrator Ronald Dato and copy report left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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