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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004570
Report Date: 08/10/2023
Date Signed: 08/16/2023 08:44:07 AM

Document Has Been Signed on 08/16/2023 08:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SHERWOOD FOREST MANOR 3FACILITY NUMBER:
507004570
ADMINISTRATOR:QUINCY BELTRANFACILITY TYPE:
735
ADDRESS:705 WINFIELD PLACETELEPHONE:
(209) 579-7545
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 4DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Quincy Beltran TIME COMPLETED:
02:00 PM
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On 08/10/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced facility to conduct an Annual Visit. LPA Pascua was greeted by Licensee representative, Sean Alicante and explained the purpose of the visit. Shortly after, LPA Pascua met with Facility Designated Administrator, Quincy Beltran.
This facility is licensed to served and accept up to 6 residents who are deemed to be non-ambulatory only. This facility is also vendorized to accept and retain Level 4F residents at this time.
Census was currently at 4. 4 out of 4 residents were out at their respective day program. A brief interview with, Licensee Alicante was conducted.

LPA reviewed 4 resident files. 4 out 4 resident files were complete and up to date. LPA reviewed 4 staff files. 4 out of 4 staff files were complete and up to date. Tour of the facility was conducted.

Fire extinguisher located by the dining room appeared to have been annually inspected by the Cal-State Fire on 04/20/2023.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Food storage units were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time. Additional non-perishable food supply was identified in the pantry.
LPA Pascua observed a locked centralized stored medication cabinet located in the dining room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the garage was conducted. Additional storage for supplies were stored in cabinets. Additional incontinence supplies were also identified.
A tour of the laundry room was conducted. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SHERWOOD FOREST MANOR 3
FACILITY NUMBER: 507004570
VISIT DATE: 08/10/2023
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A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.

A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.

A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

The exterior of the physical plant was inspected. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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Document Has Been Signed on 08/16/2023 08:44 AM - It Cannot Be Edited


Created By: Arielle Pascua On 08/10/2023 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHERWOOD FOREST MANOR 3
FACILITY NUMBER: 507004570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring that the facility is free and clear of items in the backyard area. LPA observed several unused items placed throughout in the backyard and observed a back fence that is coming off the original frame. This poses a potential health,safety or personal risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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The licensee shall clean out the items in the backyard to ensure that the backyard is free of debris. Pictures of cleaned out backyard and replaced fence shall be sent to LPA Pascua by the POC Date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation, the licensee did not comply with the section cited above in by not ensuring that there was a sufficient amount of non-perishable food supply at all times. This poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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The licensee shall ensure that a proper amount of 7 day non-perishable food supply is at the facility at all times. A statement of acknowledgement stating that the regulation was read to it's entirety shall be conducted. A copy of the statement of acknowledgement and a picture of the 7 day non-perishable food supply shall be sent to the LPAs email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


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