<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005675
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:53:10 PM

Document Has Been Signed on 03/11/2022 03:53 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:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:QUINCY BELTRAN - ADMINISTRATORTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual Inspection Infection Control visit on this date. LPA was greeted and met with Quincy Beltran Administrator. (AD)
Administrator Certificate for AD expires April 18, 2022. Liability Insurance expires .

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 110.2F degrees in kitchen sink 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 expires 1/13/2023. Fire alarm and carbon monoxide functional. LPA observed sharps and toxins locked.

LPA reviewed two staff and 2 resident files. LPA observed all staff files complete. LPA and AD observed centrally stored medications.

All persons in facility vaccinated. LPA observed resident practicing social distancing. LPA observed thirty days of PPE supplies.
LPA observed residents had activities and all residents were engaged in their own activities. LPA observed two caregivers in the facility. All caregivers were attentive to all residents.
Staff and visitors enter the facility through ringing the locked front door, sanitizer and thermometer were observed. COVID -19 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.
LPA Wallace requested the following documents to be submitted via email by March 18, 2022:
LIC - 308 Designation of Responsibility and LIC - 500 Personnel Report

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 to AD.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1