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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701154
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:39:35 PM

Unsubstantiated


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
10/24/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20221024165316
FACILITY NAME:SHERRY'S RCFEFACILITY NUMBER:
342701154
ADMINISTRATOR:AHUJA, SHERRY V.FACILITY TYPE:
740
ADDRESS:3996 WILDROSE WAYTELEPHONE:
(650) 690-4881
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Sherry AhujaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility accepting residents beyond the level of care they can provide.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Sherry's RCFE on 11/17/22 at 12:20pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because Resident #1 denied that she was unable to transfer from her bed. Resident #1 (R1) and Staff interviewed stated to LPA that R1 was able to transfer out of bed with the assistance of a sliding board and was able to transfer out of bed and into wheelchair. LPA also conducted interview with A1 who disputed the allegation and stated he had positive impressions of the facility and felt the staff were able to meet the resident's needs. Facility also utilized a Hoyer lift for R1 who distrusted the assistive device and would often refuse to utilize. As R1 has been relocated LPA was unable to have R1 or staff demonstrate a lift or transfer.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
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 2
Control Number 27-AS-20221024165316
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: SHERRY'S RCFE
FACILITY NUMBER: 342701154
VISIT DATE: 11/17/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Level of Care are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2