Sherwood Elderly Care Facility

Type of visit: Required - 1 Year

LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Staff Roxana Aguirre. LPA explained the purpose of the visit with the Administrator Judith Barajas via telephone. Administrator gave permission for Staff Roxana Aguirre to sign for this report. A tour of the facility was conducted with Staff. The residence was set at 75 F temperature. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication cart in the kitchen. Cleaning supplies were locked in a cabinet under the kitchen sink. Resident rooms toured. LPA observed a broken door knob in resident room. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguisher was last serviced 11/24/25. LPA checked water temperature which measured at 119.9 F. Fire drill was last conducted 12/1/25. Resident, medication and staff records were reviewed. Staff did not have training for postural supports, restricted health care plans and hospice. Staff had current medication and dementia training. Current first aid and CPR were reviewed. Licensee will submit a current facility sketch. A copy of this report with appeal rights and plan of correction was provided to the Administrator via email.the state’s words, verbatim · CDSS document, Dec 18, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure facility is in good repair Residents are not accorded dignity in their personal relationships with staff Facility is malodorous

Licensing Program Analysts LPA's Shawna Doucette and Jimmy Duarte arrived at the facility unannounced to commence a complaint investigation and deliver findings. LPA's were granted entry by Staff Roxanne Aguirre. LPA's met with Administrator Judith Barajas. LPA's interviewed Staff and Residents. Based on interviews, regarding the allegation Staff do not ensure facility is in good repair, it was undetermined if the facility was not in good repair. Facility toilet was clogged and Administrator contacted their maintenance to assist with unclogging the toilet. Interviews conducted revealed wipes being flushed down the toilet were causing the clogging and since wipes are no longer being flushed down the toilet, there has not been anymore incidents where the toilets have been clogged. Unsubstantiated Based on interviews, the allegation Residents are not accorded dignity in their personal relationships with staff, it is undetermined if residents are not accorded dignity in their personal relationships with staff. Interviews conducted revealed there were no witnesses of staff not according residents with dignity. Based on interviews and observation regarding the allegation Facility is malodorous, it is undetermined if there was a time the facility was malodorous. Interviews revealed there has not been a malodorous smell in the facility. LPA was at the facility on 8/16/25 and today and did not smell a malodorous smell. Based on interviews, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 24-AS-20250811105905

Type of visit: Case Management - Deficiencies

Licensing Program Analysts LPA's Shawna Doucette and Jimmy Duarte arrived at the facility unannounced to conduct a complaint investigation. During the course of the investigation LPA's observed other deficiencies. LPA's met with Administrator Judith Barajas. LPA's conducted a tour of the facility. LPA's observed a wooden stick in the sliding glass door preventing the door from opening. LPA observed staff place a chair in front of the front door blocking the doors so residents could not exit. Refer to 809d An exit interview was conducted and plans of corrections and appeal rights were issued and copy of this report was provided. Civil penalties were issued.the state’s words, verbatim · CDSS document, Sep 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 11, 2025

87202 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 was not met as evidenced by: Licensee did not ensure fire clearance was maintained by using a wooden stick to prevent sliding glass door from opening and using a chair to block the front door preventing residents from exiting which poses an immediate health safety and or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Licensee agrees to remove the wooden stick preventing the sliding glass door from opening and removing the chair from blocking the front door by POC due date 9/11/25. POC was cleared during visit. Civil Penalty was issued.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(1) · Plan of correction due date: Sep 12, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Licensee did not ensure staff accorded residents with dignity in their personal relationships by not allowing residents to go outside of the facility which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Licensee agrees submit a written statement to LPA by POC due date 09/11/25 on how this regulation will be met.

Allegation investigated: Staff handled resident in a rough manner Staff spoke inappropriately to resident Facility has inadequate food service for the residents in care

Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit and was granted entry by Staff Roxana Aguirre. LPA explained the purpose of the visit. LPA contacted Administrator Judith Barajas via telephone who responded to assist with the visit. LPA interviewed resident and staff. LPA interviewed R1's responsible party. LPA reviewed Hall ambulance records and resident records. Facility did not have a hospice care plan for R1. R1's 602 did not list primary or secondary diagnosis. Based on interviews conducted faciity staff did not handle resident in a rough, speak inappropriately to resident or have inadequate food service for residents in care. It is undetermined if there was a time any of these allegations occurred. Based on Hall ambualnce records review, there was not any documentation regarding the above allegations. Unsubstantiated Based on record reviews and interviews, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 24-AS-20241213102753

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. During the course of the investigation, LPA observed deficiencies. LPA conducted a Case Management to address the deficiencies. LPA met with Administrator Judith Barajas. During the course of the investigation of complaint 24-AS-20241213102753, LPA conducted a records review and did not locate a Hospice Care Plan for R1. LPA also reviewed R1's LIC 602 which did not have a primary or secondary diagnosis. LIC 602 did indicate the reason R1 was on hospice. Refer to 809d A copy of this report with plans of correction and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Mar 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633 · Plan of correction due date: Mar 21, 2025

87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by: Licensee did not have a care plan for R1 which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: POC Licensee agrees to submit a completed Hospice Care Plan to meet this regualtion by POC due date 03/21/25

Type of visit: Required - 1 Year

LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA explained the purpose of the visit and met with Administrator Judith Barajas. A tour of the facility was conducted with the Administrator. The residence was set at 72 F temperature and free of passageway obstructions inside and outside. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication cart in the kitchen. Cleaning supplies were locked in a cabinet under the kitchen sink. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguisher was last serviced 11/27/24. LPA checked water temperature which measured at 114.5 F. Fire drill was last conducted 12/1/24. Resident, medication and staff records were reviewed. R2 missed evening medications on 12/13/24. LPA did not locate any notes as to why the evening medications were not administered to R2. R2 did not have a home health care plan or any information as to how often Home Health is coming to the facility to care for R2's condition. Current first aid and CPR were reviewed. A copy of this report with appeal rights and plan of correction was provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 16, 2024

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Staff Roxanne Aguirre. LPA explained the purpose of the visit and staff contacted Administrator Judith Barajas who responded to the facility to assist with the visit. A tour of the facility was conducted with the Administrator. The residence was set at 77 F temperature and free of passageway obstructions inside and outside. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication cart in the kitchen. Cleaning supplies were locked in a cabinet under the kitchen sink. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguisher was last serviced 12/5/23. LPA checked water temperature which measured at 110.8 F. Fire drill was last conducted 12/1/23. Resident, medication and staff records were reviewed. Current first aid and CPR were reviewed. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 13, 2023