496804038-3-16-2023-21-AS-HDBI-CQDUYP-20230329160013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804038
Report Date: 03/16/2023
Date Signed: 03/16/2023 04:51:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2022 and conducted by Evaluator Dina Alviso

COMPLAINT CONTROL NUMBER: 21-AS-20221025142157

FACILITY NAME:	FOREVER SARAHS ELDERLY CARE CORP		FACILITY NUMBER:	496804038
ADMINISTRATOR:	JEFFERSON, JENERO		FACILITY TYPE:	735
ADDRESS:	4313 HOEN AVE		TELEPHONE:	(310) 531-6049
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	4	CENSUS: 4	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Rosilin Sadullah-Caregiver		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff did not prevent a resident from physically abusing another resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 3/16/23 at approximately 4:10PM, to deliver findings. LPA met with Rosilin Sadullah-Caregiver. LPA spoke with Lead DSP Jasmine Sampson today, regarding visits being conducted today. LPA received phone calls from the Administrator Janero Jefferson; LPA discussed the visits being conducted today.

LPA reviewed client records, including incidents, admission documents, and medication documents. The LPA reviewed other records and information obtained during the investigation. The LPA conducted interviews with staff, and other interested/related parties. LPA conducted interviews with staff (S1, S2, S3), Per staff they are trained to watch all clients and if there are situations that occur between clients the staff try to work with the clients and help diffuse any problems or arguments that may arise.
Continued on LIC9099...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221025142157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP	FACILITY NUMBER: 496804038
	VISIT DATE: 03/16/2023

NARRATIVE

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Staff stated regarding the resident incident of C1 and C2 , it was immediately addressed, and both clients were assisted, assessed, and meetings held to put a plan in place to help meet clients needs. Staff stated there was no professional medical treatment needed by the client. Staff stated that one client has been living in the home for many years, and the other client is the newest to the home. Staff state they have been working with all clients regarding any changes, and any situations that may arise. Staff(S2) stated there are house rules that staff use to help clients get along with one another. Per S2, staff are to address the incident, assess clients for any needs, and report the incident to supervisor as required. Staff are to document any incidents, and notify staff coming on duty. Staff will review incidents and try to get a plan to help clients with their behaviors and help in resolving any issues.
S2 stated that there was no previous incident that occurred where there was a physical altercation between the two clients; After this incident occurred, the facility contacted North Bay Regional Center(NBRC) to help with additional support for the client(s). LPA did interview staff and other parties, including NBRC staff.
Staff(2) stated that they have been able to retain both clients, it was agreed with NBRC, to move one of the clients into their other licensed home; Staff state both clients are doing well, and continue to be supervised as needed.

Based on LPAs observations, record reviews, and information gathered during interviews with staff, and other related parties, there is insufficient information to prove or disprove the allegation of "staff did not prevent a resident from physically abusing another resident" therefore this allegation is unsubstantiated.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged abuse occurred.
No citations issued this visit.
Exit interviews were conducted.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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