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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005675
Report Date: 07/17/2023
Date Signed: 07/18/2023 08:21:42 AM

Document Has Been Signed on 07/18/2023 08:21 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 4FACILITY NUMBER:
507005675
ADMINISTRATOR:QUINCY BELTRANFACILITY TYPE:
735
ADDRESS:3404 GLENCREST CTTELEPHONE:
(209) 857-8399
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
07/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Quincy Beltran TIME COMPLETED:
02:00 PM
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On 07/17/2023 Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a case management visit. LPA was greeted by Staff member, Mary Gonzalez and explained the purpose of the visit. LPA asked that SM Gonzalez call the Facility Designated Administrator to inform them at CCL was present. Shortly after, LPA met with FDA, Quincy Beltran and explained the purpose of the visit. An interview with FDA Beltran was conducted. Current census was 6. 2 out 6 of the facility. A tour of the facility was conducted. There were two other staff members present, Melissa Daoud and Raquel Bargas.

The purpose of this visit was to follow up on an incident report received by the department on 07/17/2023. The incident report states that there was an emergency interdisciplinary team meeting conducted on 07/14/2023.

LPA reviewed facility files including but not limited to, R1's Individual Program Plan, Emergency contact sheet, Physicians report and daily notes. LPA Pascua conducted resident and staff interviews.

Based on the information gathered today, there are no deficiences being cited during today's visit. LPA Pascua will come at a later time if further follow up is needed.

An exit interview was conducted, a copy of this report was provided to the the facility at end of this visit.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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