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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804038
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:29:28 PM

Substantiated


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
06/05/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240605093000
FACILITY NAME:FOREVER SARAHS ELDERLY CARE CORPFACILITY NUMBER:
496804038
ADMINISTRATOR:SAMPSON, JASMINEFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(310) 531-6049
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:4CENSUS: 4DATE:
11/08/2024
ANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jenero JeffersonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not provide adequate food service
Facility is having financial issues
INVESTIGATION FINDINGS:
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Community Care Licensing staff met in the Santa Rosa Regional office with Licensee, Jenero Jefferson to deliver findings regarding the above allegations. Staff did not provide adequate food service – Complaint alleges that the care home is always running out of food for the clients, sometimes resulting in staff buying food. Two of three staff interviewed referenced that they have heard of other staff buying food, but none indicated that they have bought groceries themselves. One of three interviews revealed that there is a card that the Licensee leaves at the facility for groceries or fast food and two of three staff indicating that they may text Licensee for food to be delivered, however there can be delays. LPAs visited facility on September 25, 2024 to observe food and determined there was not two days of perishable food, as required by regulation.
Facility is having financial issues – Complaint alleges that facility is not paying staff timely due to financial issues. CCL conducted an investigation that included a financial audit. Two of three staff interviewed reported a delay in their paychecks. During the August 14, 2024 Office Meeting in the Santa Rosa Regional Office it was revealed that facility was unable to pay taxes requiring the regional center to pay.
Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20240605093000
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: 11/08/2024
NARRATIVE
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Facility did not comply with CCL Auditor’s request though the minimal financial documents provided did not show that facility had sufficient operating costs.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.

Appeal rights given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240605093000
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2024
Section Cited
CCR
80062(a)(1)
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80062 Finances:The licensee shall meet the following financial requirements: (1) Development and maintenance of a financial plan which ensures resources necessary meet operating costs for care and supervision of clients.This requirement is not met as evidenced by: Based on record
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Facility to submit all documents that were originally requested by the CCL auditor no later than POC due date, 11/12/2024.
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review and interviews, the licensee did not comply with the section cited above by not ensuring that operating costs such as taxes being paid, and staff being paid timely which poses an potential health, safety or personal rights risk to persons in care.
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Type B
11/12/2024
Section Cited
CCR
80076(a)(1)
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80076 Food Services:(a)(1) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food
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Facility to submit a written plan that indicates how facility will ensure clients have access to the quantity and quality of food required by regulation. Additionally, the facility is to provide a menu for the upcoming week along with grocery receipts showing food items
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Group Plan...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on LPA observation and interviews, the licensee did not comply with the section cited above by not always ensuring the quantity of food required by regulation which poses a potential health, safety or personal rights risk to persons in care.
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have been purchased related to the menu no later than POC due date, 11/12/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3