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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005675
Report Date: 04/23/2024
Date Signed: 04/24/2024 07:54:37 AM

Document Has Been Signed on 04/24/2024 07:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SHERWOOD FOREST MANOR 4FACILITY NUMBER:
507005675
ADMINISTRATOR/
DIRECTOR:		QUINCY BELTRANFACILITY TYPE:
735
ADDRESS:3404 GLENCREST CTTELEPHONE:
(209) 857-8399
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Quincy Beltran TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 4/23/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by Staff Member (SM), Ana Contreras and explained the purpose of the visit. LPA asked that SM Contreras contact the Facility Designated Administrator (FDA), Quincy Beltran, and inform her that CCL was present at this time. There was one other staff member present, Erica Torres. Short after, LPA met with Licensee, Sean Alicante and FDA Beltran and explained the purpose of the visit.
This facility is licensed to for 6 residents who may be non-ambulatory. This facility is also vendorized by Valley Mountain Regional Center to accept and serve Level 4I residents at this time.
Current census was 5. 1 out 5 residents were out at their respective day program. 3 out 5 residents were observed to be obtaining services from an at home day program.
LPA reviewed 4 resident files and 4 staff files. The Facility Designated Administrator has an expired administrator certificate however LPA was able to confirm through the Administrator portal that administrator has sent in documentation to the department on 02/04/2024.
A tour of the facility was conducted. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour with FDA Beltran was conducted. Fire extinguisher located in the living room was serviced by Cal State Service Company on 1/12/2024.
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. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care.
A tour of the garage was conducted. Additional food supply was identified.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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 4
FACILITY NUMBER: 507005675
VISIT DATE: 04/23/2024
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A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
A tour of the 3 resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
The exterior of the physical plant was in good repair with no hazards present. 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

A technical violation is being provided today for 80075(f).

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to the facility. An exit interview was held, and a copy of the report was provided in-person and sent via email.
No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2024 07:54 AM - It Cannot Be Edited


Created By: Arielle Pascua On 04/23/2024 at 12:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERWOOD FOREST MANOR 4
FACILITY NUMBER: 507005675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that 1 out 4 staff members reviewed had an active first aid certificate on file. This poses an immediate health, safety and personal rights risks to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Licensee shall ensure that S1 obtains their first aid certificate by the POC date.
A statement of acknowledgement and correction shall also be provided to the LPA by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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