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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507005675
Report Date: 01/24/2024
Date Signed: 01/25/2024 11:43:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231016174144
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:
01/24/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Quincy Beltran TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff handled resident in rough manner
INVESTIGATION FINDINGS:
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On 01/24/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with staff member (SM), Anabel Contreras, and explained the purpose of the visit. LPA asked that SM Contreras call the Facility Designated Administrator (FDA), Quincy Beltran to inform them that CCL was present at this time. Shortly after, LPA met with FDA Beltran and explained the purpose of the visit.
The purpose of this visit was to deliver complaint findings for the allegation above.
Current census was 5. 2 out 5 residents were out at their respective day programs at this time. A brief interview with FDA Beltran was conducted.
It was alleged that staff handled a resident in a rough manner. During the course of this investigation the LPA conducted interviews and reviewed records. Based on interviews conducted it was learned that Resident 1 (R1) was sitting in their mobilized chair when they were asking for some help. Staff 1 (S1) was sitting on the couch behind R1 waiting to start their shift at the time. It was stated that there were 2 other staff members present and on the clock at this this time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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 3
Control Number 27-AS-20231016174144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/24/2024
NARRATIVE
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Staff 2 (S2) came behind R1’s chair and became frustrated. S1 then witnessed S2 reach for the back of R1’s chair and grabbed the handles and picked up the chair and dropped it in a rough manner while the resident was in the chair. An interview with Staff 3 was conducted, which confirmed that S2 picked up the resident’s chair and dropped it while the resident was in the chair.

Based on the information gathered, the staff handled a resident in a rough manner.

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

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20231016174144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2024
Section Cited
CCR
80072(a)(3)
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(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Licensee shall a review of the section, 80072(a)(3), will be conducted. A statement of correction, and 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 arielle.pascua@dss.ca.gov.
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This is not met as evidenced by: Based on interviews it was learned that S2 picked up the resident’s chair and dropped it in a rough manner while the resident was still present and sitting on the chair. This poses an immediate health, safety, and personal rights risks to persons in care.
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by the due date of 1/25/2023 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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3