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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005675
Report Date: 12/06/2021
Date Signed: 12/06/2021 01:58:43 PM

Document Has Been Signed on 12/06/2021 01:58 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 4FACILITY NUMBER:
507005675
ADMINISTRATOR:QUINCY BELTRANFACILITY TYPE:
735
ADDRESS:3404 GLENCREST CTTELEPHONE:
(209) 857-8399
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Quincy Beltran, Administrator, ADTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Raquel Bargas, Caregiver (R!) and met with Quincy Beltran, Administrator. (AD)

LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas. LPA observed the backyard that was free of debris .Hot water temperature measured 117 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees.

LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies..
Last Fire Drill conduced dated 11/15//21. Fire extinguisher maintained 1/14/2021.
Fire alarm and carbon monoxide functional. LPA observed sharps and toxins locked.
LPA and AD observed centrally stored medications.

LPA reviewed 4 staff and 5 resident files. LPA observed all staff files complete.
Administrator Certificate valid 4/18/22. Liability Insurance current and meet criteria.
All persons in facility fully vaccinated.
LPA observed resident practicing social distancing. LPA observed 30 days PPE supply.
LPA observed residents had activities and all residents were engaged in their own activities. LPA observed 3 caregivers in the facility. All caregivers were attentive to all residents. LPA observed a resident requesting to outside. LPA observed the caregiver ensuring the resident was properly dressed and protected from cold weather and took the resident outside.

809 CONT. >>>>>>>>>>>>>>>>>>>>>
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SHERWOOD FOREST MANOR 4
FACILITY NUMBER: 507005675
VISIT DATE: 12/06/2021
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Staff and visitors enter the facility through ringing the locked front door, sanitizer and thermometer were observed. COVID signs posted in front entry way or throughout the facility. LPA observed masks and hand sanitizer available to visitors.

Sign in sheets were observed to document date, visitors name, and temperature. Sign in sheets did include symptom screening for reporting requirements to public health officer and contact tracing.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No 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: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC809 (FAS) - (06/04)
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