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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507002679
Report Date: 05/31/2022
Date Signed: 05/31/2022 12:19:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/23/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220523082314
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: 4DATE:
05/31/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Ronaldo DatoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility has an RSO present at the facility.
INVESTIGATION FINDINGS:
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LPA Jason Lund arrived at the above facility unannounced to open and complete a complaint investigation for the above facility. LPA Lund met with Administrator Ronaldo Dato and explained the purpose of today's visit.

Facility has an RSO present at the facility- The Department of Social Services received a report that a staff (S1) was convicted of a crime and is now on the Registered Sex Offender (RSO) list and can’t no longer work or be at the facility. On May 23, 2022 facility received an order to Licensee/Facility of Immediate Exclusion from Facility, from the Department of Social Services staff member. The Department confirmed that S1 was still working at the facility and Department personal confirmed that S1 was not at the facility on May 23,2022 and last worked on May 20, 2022. Department personnel served the Administrator Ronaldo Dato the Licensee/Facility of Immediate Exclusion from Facility, On May 23, 2022, S1 was Excluded.

Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220523082314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 2
FACILITY NUMBER: 507002679
VISIT DATE: 05/31/2022
NARRATIVE
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As a result of this investigation, LPA finds allegation to be (S)Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations.

Exit interview was conducted with Administrator Ronaldo Dato. A copy was left, and appeal rights given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220523082314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 2
FACILITY NUMBER: 507002679
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2022
Section Cited
CCR
87355(d).
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(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
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The Administrator will look over the regulation and send LPA Lund an email that Administrator understands the regulation.
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 This requirement was not met as evidenced by: May 23, 2022 facility received an order to Licensee/Facility of Immediate Exclusion from Facility, from the Department of Social Services staff member. This poses an immediate health and safety issue
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3