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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701356
Report Date: 07/17/2025
Date Signed: 07/17/2025 10:47:08 AM

Document Has Been Signed on 07/17/2025 10:47 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SHERRY'S RCFE LLCFACILITY NUMBER:
342701356
ADMINISTRATOR/
DIRECTOR:		AHUJA, SHERRY V.FACILITY TYPE:
740
ADDRESS:10609 CHARBONO WAYTELEPHONE:
(650) 690-4881
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 6CENSUS: 6DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Sherry Ahuja TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 07/17/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by staff member, Lydia Wilkie and explained the the purpose of the visit. LPA also called the Facility Designated Administrator (FDA), Sherry Ahuja and informed her that CCL was present at this time. It was stated by FDA Ahuja that she would be at the facility within 30 minutes. There was one other staff member present at the time of LPA Pascua's arrival, Ryan Mapp.

Current census was 5. This facility is licensed to serve 6 residents who are 60 and older. Of the 6 residents, all may be on hospice, 3 may be non-ambulatory and 1 may be bedridden. The bedridden room is cleared by the local fire department for bedroom #5 only. In addition, non-ambulatory residents may reside only in bedrooms #3 and bedroom #4. Ambulatory residents are to reside in bedroom #1 and #2. Bedroom #2 is the only shared bedroom at the time of the fire clearance.

LPA reviewed 5 resident files. Based on the file review conducted, it was learned that 5 out 5 resident files did not have a current needs and services plan. 3 out 5 residents did not have an inventory sheet or a pre placement appraisal. LPA reviewed 3 staff files. Based on filed review conducted, it was learned that 3 out 3 staff members do not have current annual training and staff files appears to have documentation from prior facility. The current FDA has an active administrator certificate #7027497740 and expires on 01/30/2026.
A tour of the facility was conducted.
A tour of the kitchen was conducted. LPA observed a sufficient amount of 2-day perishable and 7 day non-perishable food supply. LPA observed knives and toxins locked and made inaccessible to residents in care.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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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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Document Has Been Signed on 07/17/2025 10:47 AM - It Cannot Be Edited


Created By: Arielle Pascua On 07/17/2025 at 09:40 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERRY'S RCFE LLC
FACILITY NUMBER: 342701356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
(2) Eight hours of in-service training per year on the subject of serving residents with dementia."
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not not comply with the section cited above by not ensuring that 3 out 3 staff members did not have annual RCFE training. This poses a potential health, safety and personal rights risks to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Licensee shall conduct RCFE training for all staff. A copy of staff training shall be send to the LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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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 LLC
FACILITY NUMBER: 342701356
VISIT DATE: 07/17/2025
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A fire extinguisher was also located in the kitchen and last serviced on 11/22/2023 by Jorgenson Co and is not in compliance at this time. LPA Pascua observed the local Fire Extinguisher company arrived at the time of the visit to service the extinguishers.
A tour of the living area, dining area, and other areas intended for resident use was conducted. Furniture was observed to be in good repair and meet resident needs.
A tour of 3 bathrooms were conducted. Hot water was taken to ensure compliance within regulation. Grab bars were present and in good repair.
A tour a 4 resident bedrooms were conducted. Resident furniture was observed to be in good repair and meet residents needs. 2 additional staff bedrooms was toured.
A linen closet was identified and presented a sufficient amount of linens to meet the needs of the residents.
Carbon monoxide and smoke alarms were observed and tested to ensure it was in proper working condition.
A tour of the garage was conducted. Toxins and other cleaning supplies were identified and made inaccessible to residents in care.
A tour of the back yard was conducted with no hazards present. Perimeter fence and exit gates were observed to be in good repair.

The following documentation was requested to be submitted to the department:
-LIC 308
-LIC 500
-LIC610e
-Liability insurance

A technical violation was provided for Sections 87506(a) and 87412(a).

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. The Licensee was informed at the time of the visit that failure to complete Plan of Corrections (POC) by the POC date may result in additional civil penalties.

An exit interview was conducted and a copy with appeals rights. of this report was provided to the administrator at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/17/2025 10:47 AM - It Cannot Be Edited


Created By: Arielle Pascua On 07/17/2025 at 10:17 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHERRY'S RCFE LLC
FACILITY NUMBER: 342701356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring the the fire extinguishers have been serviced within the last 12 months. LPA observed the fire extinguisher was last serviced in November 2023. This poses an immediate health, safety, and personal rights risks to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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During the course of this visit, LPA observed the local fire extinguisher company arrive at the time of LPAs visit. Citation will be cleared today.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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