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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002679
Report Date: 10/25/2023
Date Signed: 10/29/2023 09:41:33 PM


Document Has Been Signed on 10/29/2023 09:41 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: DATE:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Ronald Dato TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met with Administrator Ronald Dato and explained the reason for the visit. Census 3

LPA Lund & Ronald Dato inspected/toured the facility. This is a Level 4 Regional Center vendorized home. There are three client bedrooms and two bathrooms for clients and the facility currency has 4 clients. LPA observed bedrooms to be properly furnished, with appropriate lighting. The bathrooms were in sanitary condition, properly maintained.

LPA checked the kitchen area and observed there are 2- days perishable and 7- days of non-perishable food supply. LPA observed toxins inside the home to be locked away and inaccessible to clients. Smoke detectors were tested and are operational and care home also has a carbon monoxide detector. Facility has a built-in sprinkler system. Fire extinguishers (1/12/23) and first aid kit are maintained and ready for emergency use. Care home also conducts monthly fire/disaster drills documented in a fire drill log. LPA reviewed two staff & two residents files.

No deficiencies were citied during this inspection. Exit interview held with Administrator Ronald Dato and copy report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
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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