<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002679
Report Date: 10/26/2021
Date Signed: 10/26/2021 11:55:56 AM

Document Has Been Signed on 10/26/2021 11:55 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:SHERWOOD FOREST MANOR 2FACILITY NUMBER:
507002679
ADMINISTRATOR:RONALDO DATOFACILITY TYPE:
740
ADDRESS:601 E. RUMBLE ROADTELEPHONE:
(209) 577-1247
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Ronaldo DatoTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jason Lund made an unannounced visit to this facility to conduct an Annual Required visit and met with Administrator Ronald Dato. Administrator's Certificate #5041056740 Expires 9/22/22.

LPA Lund & Ronald Dato toured the facility. All six staff and four clients have been vaccinated. This is a Level 4 Regional Center vendorized home. There are three client bedrooms and two bathrooms for clients and the facility currency has 4 clients. LPA observed bedrooms to be properly furnished, with appropriate lighting. The bathrooms were in sanitary condition, properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed there are two days worth of perishable and 7 days of non-perishable food supply. on hand. LPA observed toxins inside the home to be locked away and inaccessible to clients. Smoke detectors were tested and are operational and care home also has a carbon monoxide detector. Facility has a built-in sprinkler system. Fire extinguishers and first aid kit are maintained and ready for emergency use. Care home also conducts monthly fire/disaster drills documented in a fire drill log..

No deficiencies were identified on this inspection.

Exit interview held and copy of report given at the conclusion of this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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 1