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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005675
Report Date: 03/22/2023
Date Signed: 03/22/2023 12:20:24 PM

Document Has Been Signed on 03/22/2023 12:20 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: 6DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Quincy Beltran TIME COMPLETED:
01:00 PM
NARRATIVE
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On 03/22/2023 at 12:00pm, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct a case management visit. LPA was greeted by Facility Designated Administrator (FDA), Quincy Beltran and explained the purpose of the visit. There were 3 other staff member present during the course of this visit, Anabel Contreras, Mellissa Daoud, and Mary Gonzalez. Current Census was 6.
A tour of the facility was conducted. A brief interview with FDA Beltran was conducted.

The purpose of this visit was to follow up on an incident reported received by the department on 03/16/2023. The incident report states that on 03/14/2023, the Administrator was administrating evening and night medication for the facility around 7pm and noticed that one medication was missing from the resident one (R1) bubble pack. This medication was intended to be provided in the evening and was not given the medication yet according to the medication dispensing log. The administrator conducted an internal investigation and learned that the morning staff member (S1) admitted that they provided the medication in at noon and realized after given to the resident that it was an evening medication.

Based on interviews and file review, Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiency is being cited on the attached 809D during this visit.

An exit interview was conducted and a copy of this report, appeal rights and a copy of the confidential names list were given to the Administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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Document Has Been Signed on 03/22/2023 12:20 PM - It Cannot Be Edited


Created By: Arielle Pascua On 03/22/2023 at 11:51 AM
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
, 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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited
CCR
80065(f)(4)

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80065 Personnel Requirement
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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Facility Administrator stated that a review of the section, 80065(f)(4), 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 arielle.pascua@dss.ca.gov
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4) Assistance with prescribed medications which are self-administered.
This requirement was not as evidenced by:
Based on interview and LPAs review of facility records, it was found that R1 was provided medication outside of it's prescription order. R1 was provided their medication in the noon time rather than in the evening based on physicians orders.
This poses a potential health, safety and personal risk to residents in care
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by the due date of 04/07/2023 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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
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