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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701154
Report Date: 08/01/2023
Date Signed: 08/01/2023 10:57:30 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
07/27/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230727115647
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: 2DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not address resident’s toileting needs
Staff did not assist resident with showering

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Sherry's RCFE on 8/1/23 at 8:30am to inform the licensee of complaint allegations mentioned above and deliver findings.

During this investigation LPA Gould interviewed two staff members, one former resident (R1) and the reporting party (RP) (See confidential name list LIC-811 dated 8/1/23).

Based on interviews conducted and statements obtained during the investigation process, the above allegations were corroborated by RP and R1 that the staff members did not follow the physician report indicating the resident required assistance with showering and toileting needs. Per interviews a portable commode was provided to resident but no assistance was provided. Additionally, both parties interviewed corroborated that R1 received one shower while in placement and staff did not provide direct assistance and only provided stand-by assistance that did not meet all the resident's needs with assistance with daily living. Licensee denies the allegations.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 5
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
07/27/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230727115647

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: 2DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sherry Ajula TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
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9
Food services do not meet resident’s needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Sherry's RCFE on 8/1/23 at 8:30am to inform the licensee of complaint allegations mentioned above and deliver findings.

During this investigation LPA Gould interviewed two staff members, one former resident (R1) and the reporting party (RP) (See confidential name list LIC-811 dated 8/1/23). Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations because LPA did not observe any specific food or special diet indicated on the physician's report. R1 when interviewed stated the facility worked with her to identify items she would like to eat. Per the 602 it states 21 allergies and to see an attachment but none was provided to the licensee upon admission.

report continues on lic 9099-c
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230727115647
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: 08/01/2023
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 food services are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies cited per California Code of Regulations, TITLE 22.

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

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230727115647
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: 08/01/2023
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of neglect/lack of supervision is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22

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

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230727115647
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
Section Cited
CCR
87464(f)(4)
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Basic Services: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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LPA and licensee developed a plan for the facility to incorporate a ADL checklist for all residents and staff will mark down when a service is provided by staff or declined by a resident. licensee will provide a copy of the checklist.
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this requirement was not met as evidenced by statements obtained from R1 and RP who indicated the facility did not provide assistance with toileting or showering to meet the resident's needs per their physician report. which poses a potential health, safety and personal rights risk to residents in care.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5