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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701154
Report Date: 04/22/2025
Date Signed: 04/22/2025 01:13:56 PM

Document Has Been Signed on 04/22/2025 01:13 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SHERRY'S RCFEFACILITY NUMBER:
342701154
ADMINISTRATOR/
DIRECTOR:		AHUJA, SHERRY V.FACILITY TYPE:
740
ADDRESS:3996 WILDROSE WAYTELEPHONE:
(650) 690-4881
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 6DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sherry AhujaTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Sherry Ahuja and explained the purpose of the visit.

Upon entry, LPA Moleski observed an individual working in the kitchen (S1). S1 identified themselves to LPA Moleski. S1 initially said they were at the facility visiting someone. LPA Moleski had already spoken with another staff member (S2), who said S1 started training last week. After LPA Moleski relayed this information to S1, S1 admitted that they were here for caregiver training. Ahuja said that S1 started training on either April 16 or 17. LPA Moleski observed in the facility garage a bed and personal effects. S1 said they had been sleeping in the bed, and that some of the effects were theirs. This facility is not cleared for residential use of the garage area. LPA Moleski reviewed Guardian records and observed that S1 does not have a criminal record clearance. S1 had no personnel record on file. Ahuja said she wanted to help out S1 by giving them a place to stay.

LPA Moleski reviewed six resident files (R1-R6) and three staff files (S2-S4). S4's file did not contain an LIC 501, LIC 508, or first aid/CPR certification. LPA Moleski observed in a resident's file (R1) medical documentation showing that R1 visited the hospital on 2/10/25 due to a wound on R1's foot. According to Ahuja, a wound on R1's foot had gotten worse, and needed medical attention. R1 was placed on hospice care after this visit, according to Ahuja. LPA Moleski reviewed fax and email records and observed no incident report was received by the Community Care Licensing Division (CCLD) regarding this incident. Additionally, no notification was made when R1 started receiving hospice care. LPA Moleski observed in another resident's file (R2) medical documentation showing that R2 was hospitalized and placed on a 5150 hold on 3/13/25. According to Ahuja, R2 was hearing voices and was experiencing paranoia, so they were taken to the hospital. [continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SHERRY'S RCFE
FACILITY NUMBER: 342701154
VISIT DATE: 04/22/2025
NARRATIVE
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LPA Moleski reviewed fax and email records and observed that no incident reports were received by CCLD regarding this incident. LPA Moleski observed in another resident's file (R4) medical documentation showing that R4 was sent to the hospital due to a lice infestation. CCLD received no incident report of this, according to fax and email records.

While reviewing R4's medication administration records (MARs), LPA Moleski observed a lice treatment medication for R4 which was to be taken once per day, according to the MARs and according to the centrally stored medication records sent by R4's pharmacy. The medication was filled as of 3/11/25, according to the MARs. LPA Moleski observed that R1 received the medication at sporadic intervals, sometimes once every other day, once every two days, or with multiple days in between doses. S2 said that R4 did not receive the medication every day because R4 did not receive a shower every day. This facility has two scheduled shower days per week per resident. LPA Moleski asked for the prescription order for this medication, but Ahuja was not able to immediately produce it. Ahuja obtained an electronic copy and sent it to LPA Moleski.

LPA Moleski toured the facility with Ahuja and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 76 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 103 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S2) and one resident (R3).This facility is hereby cited per 22 CCR Sections 87202(a), 87355(e), 87465(a)(4), 87211(a)(1), 87303(e)(2), 87412(b), and 87632(d)(2). Due to a violation of fire clearance, an immediate civil penalty of $500 is hereby assessed. Due to a violation of criminal record clearance requirements, a civil penalty in the amount of $100 per day of S1's work and/or residence at this facility, with a maximum of 5 days, is hereby assessed. Civil penalties assessed during this visit total $1000. An exit interview was held with Ahuja. Appeal rights and a copy of this report were left with Ahuja.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/22/2025 01:13 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/22/2025 at 12:39 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERRY'S RCFE
FACILITY NUMBER: 342701154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) 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 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, S1 was living in the facility garage without an appropriate fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a photograph showing all beds and personal effects removed from the garage by POC due date.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, S1 was working and/or residing in this facility since approximately April 17 without a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a written plan describing their plan for S1 (either permanent removal, or clearance and association) by POC due date.
vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/22/2025 01:13 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/22/2025 at 12:39 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERRY'S RCFE
FACILITY NUMBER: 342701154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, a resident did not receive their daily medications, and that same resident was given medications without a prescription order on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a date for scheduled staff training on medication administration by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/22/2025 01:13 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/22/2025 at 12:39 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERRY'S RCFE
FACILITY NUMBER: 342701154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, multiple incidents were not reported to CCLD, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with the missing incident reports as described in this report, and a written plan describing their incident reporting procedures by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperatures were not maintained within the required range, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
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2
3
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Licensee adjusted the water heater during this visit. Licensee agrees to provide LPA Moleski with a photograph of a new temperature reading by POC due date.
vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2025 01:13 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/22/2025 at 12:39 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERRY'S RCFE
FACILITY NUMBER: 342701154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(b)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, at least one staff person's personnel record was not complete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
1
2
3
4
Licensee agrees to provide LPA Moleski with S4's complete personnel file by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87632(d)(2)
Hospice Care Waiver
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, notice of initiation of hospice services were not received by CCLD, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
1
2
3
4
Licensee agrees to provide a written plan describing how these reports will be sent in to licensing.
vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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