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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701154
Report Date: 08/01/2023
Date Signed: 08/01/2023 10:58:54 AM

Document Has Been Signed on 08/01/2023 10:58 AM - 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: 2DATE:
08/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sherry Ahuja TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management deficiencies inspection at Sherry's RCFE on 8/1/23 at 8:30am to address LPAs observations that the garage has been converted to a bedroom and is not a part of the facility's fire clearance.

LPA observed a bed in the garage and LPA compared the facility sketch from the pre-licensing inspection and LPA did not observe that the garage was identified as a staff bedroom and was not indicated on the facility sketch. The facility is currently not in compliance with their fire clearance.

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
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 08/01/2023 10:58 AM - It Cannot Be Edited


Created By: Kevin Gould On 08/01/2023 at 10:32 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: 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 A
08/02/2023
Section Cited
CCR
87202(a)

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an
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Facility will follow up with fire marshal and obtain a new fire clearance that includes the garage being utilized as a bedroom.
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appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by LPA observations of a bed in the garage and statements from staff that indicate they sleep in the garage and was not part of the facility's initial fire clearance. 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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