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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507005675
Report Date: 09/15/2023
Date Signed: 09/21/2023 10:29:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230712143551
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:
09/15/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Quincy Beltran TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff are verbally abusive to residents.
INVESTIGATION FINDINGS:
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On 09/15/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility unannounced to conduct a complaint visit. LPA Pascua was greeted by Staff Member (SM), Mary Gonzalez and explained the purpose of the visit. LPA Pascua asked that SM Gonzalez call the Facility Designated Administrator to inform them at CCL was present.
Current Census was 6. 2 out of 6 residents were out at their respective date program at this time.
The purpose of this visit is to delivery complaint findings for the allegation above.
It was alleged that the facility staff are verbally abusive to residents. During the course of this investigation LPA reviewed facility documents and conducted interviews. LPA interviewed 8 facility staff members and 5 residents. Based on interviews conducted, it was learned that it was observed that S1 has been yelling at several residents during their shift at the facility.
Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.An exit interview was conducted, a copy of the LIC9099 and 9099-D, and appeals rights was provided to the Facility Designated Administrator, Quincy Beltran.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
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 4
Control Number 27-AS-20230712143551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2023
Section Cited
CCR
80072(a)(1)
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(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This is not met as evidenced by: Based on interviews it was learned that multiple staff members have been yelling at the residents. This poses an immediate health, safety, and personal rights risks to persons in care.
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Licensee shall a review of the section, 80072(a)(1), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at
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arielle.pascua@dss.ca.gov. by the due date of 09/18/2023 COB. Information submitted must include attendees, trainers, and information discussed.
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230712143551

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:
09/15/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Quincy Beltran TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Facility staff are mentally abusive to residents.
Facility staff are physically abusive to residents.
INVESTIGATION FINDINGS:
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On 09/15/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility unannounced to conduct a complaint visit. LPA Pascua was greeted by Staff Member (SM), Mary Gonzalez and explained the purpose of the visit. LPA Pascua asked that SM Gonzalez call the Facility Designated Administrator to inform them at CCL was present. The purpose of this visit is to deliver complaint findings for the allegations
Current Census was 6. 2 out of 6 residents were out at their respective date program at this time.
Allegation: Facility staff are mentally abusive to residents
It was alleged that facility staff are mentally abusive to residents. During the course of this investigation LPA reviewed facility documents and conducted interviews. LPA interviewed 7 staff members. 7 out 7 staff members state that they do not believe that they cause any mental abusive to the residents. 3 out 7 staff members state that they have witnessed verbal abuse but do not believe that it causes the residents any distress. 4 out 7 staff members deny that they have seen other staff members cause mental abuse to the residents. An interview with 5 residents were conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230712143551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/15/2023
NARRATIVE
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 4 out 5 residents report not receiving any mental abusive. 1 out of 5 residents denied being interviewed.
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.

Allegation: Facility staff are physically abuse to residents

It was alleged that facility staff are physically abusive to residents. During the course of this investigation LPA reviewed facility documents and conducted interviews. LPA interviewed 7 staff members. 7 out 7 staff members state that they do not believe that they cause any mental abusive to the residents. 2 out 7 staff members state that they have witnessed a staff member lay their hand over a resident’s face. 3 out 7 stated that they have heard that a staff member would lay their hand over a resident’s face but have not observed it themselves. 2 out 7 staff members denied ever seeing any staff members physically abuse a resident. An interview with 5 residents were conducted. 4 out 5 residents report not receiving any physical abuse. 1 out of 5 residents denied being interviewed.

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: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4