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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701154
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:38:41 PM

Document Has Been Signed on 11/17/2022 02:38 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: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: 4DATE:
11/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Sherry AhujaTIME COMPLETED:
03:00 PM
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On 11/17/22 at 12:20pm Licening Program Analayst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure previously cited deficiencies have been corrected an to review medication administration logs for continued compliance with regulations. LPA met with Licensee and together reviewed POC documents.

LPA reviewed Medication Administration records for all residents in care and observed no errors in documentation of medication administration. Additionally LPA reviewed written plan of correction which meets requirements for the correction. The previous deficiency has been cleared and a POC clearance letter generated.

an exit interview was conducted 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
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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