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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004570
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:17:53 PM

Document Has Been Signed on 08/22/2024 01:17 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 3FACILITY NUMBER:
507004570
ADMINISTRATOR/
DIRECTOR:		QUINCY BELTRANFACILITY TYPE:
735
ADDRESS:705 WINFIELD PLACETELEPHONE:
(209) 579-7545
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Quincy Beltran TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 08/22/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Quincy Beltran and explained the purpose of this visit.

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, FDA Beltran was conducted.

LPA reviewed 4 resident files. 4 out 4 resident files were complete and up to date. LPA reviewed 5 staff files. 5 out of 5 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 04/17/2024.

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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 3
FACILITY NUMBER: 507004570
VISIT DATE: 08/22/2024
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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

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.

Exit interview.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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