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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002679
Report Date: 11/13/2024
Date Signed: 11/13/2024 10:46:53 PM

Document Has Been Signed on 11/13/2024 10:46 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 MANOR 2FACILITY NUMBER:
507002679
ADMINISTRATOR/
DIRECTOR:
RONALDO DATOFACILITY TYPE:
740
ADDRESS:601 E. RUMBLE ROADTELEPHONE:
(209) 577-1247
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator Ronald DatoTIME VISIT/
INSPECTION COMPLETED:
12:30 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. The facility is Regional Center home for Level 4I clients. There are three client bedrooms and two bathrooms for 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 (1/11/24) 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 (9/30/2024). LPA reviewed two staff & two residents files and were in compliance.
No deficiencies were citied during this inspection. Exit interview held with and copy report left.
Lisa RiosTELEPHONE: (916) 969-9685
Jason LundTELEPHONE: (916) 223-6752
DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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