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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004570
Report Date: 06/18/2024
Date Signed: 06/26/2024 11:13:43 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240207153037
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: DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Quincy Beltran TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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 Staff hit resident in the back.
INVESTIGATION FINDINGS:
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On 06/18/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA was greeted by staff member, Amelia Guideng and explained the purpose of the visit and was asked to the Facility Designated Administrator (FDA), Quincy Beltran to inform her that CCL was present at this time.

Current census is 4. 4 out of 4 residents were out at their respective day programs at this time.
The purpose of this visit was to deliver complaint findings for the allegation above.
It was alleged that a staff member hit a resident in the back. During the course of this investigation, LPA conducted interviews which disclosed that staff were present at the time of an incident and witnessed a resident hit another resident on the back. It was stated by 3 staff members present during the incident that the resident was irritated and decided to kick the back of the residents wheelchair which may have caused them discomfort. 3 out 3 staff members deny ever hitting the resident on the back. 3 out 3 staff stated that after the incident, they checked on both residents if they needed any immediate medical attention.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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 2
Control Number 27-AS-20240207153037
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/18/2024
NARRATIVE
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An interview with 4 residents were attempted however, the LPA was unable to corroborate any information due to medical issues.
Based on the information gathered, it is unclear that the staff hit the resident on the back.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.



There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2