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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 12/18/2024
Date Signed: 12/18/2024 02:21:19 PM

Document Has Been Signed on 12/18/2024 02:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FOREVER SARAHS ELDERLY CARE CORPFACILITY NUMBER:
496804038
ADMINISTRATOR/
DIRECTOR:		MCDANIEL, JUANITAFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(707) 526-1808
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: 4DATE:
12/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Administrator, Juanita McDanielTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst Robert Frank and Licensing Program Manager Victoria Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Juanita McDaniel.

CCL received information that the facility water was shut off today, December, 18, 2024 due to non-payment. CCL staff confirmed with the local water company that the water was turned off for non-payment but the bill had since been paid and the water would be turned back on by 4:00pm today. Upon arrival, CCL staff confirmed that the water had been turned back on. Facility has the amount of food required by regulation. Facility was observed to have power and heat. Facility was comfortable in temperature. Facility van has expired registration tags that expired September, 2024 though it is unclear if the registration has not been paid.

No deficiencies cited during this visit.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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