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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 12/27/2024
Date Signed: 12/27/2024 03:08:37 PM

Document Has Been Signed on 12/27/2024 03:08 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: DATE:
12/27/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:44 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:23 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a plan of correction visit and was greeted by caregiver. Licensee Jenero Jefferson was not available to come to the facility, was not available by phone and their voicemail box was full, so LPA could not leave a message.

On 12/19/24 LPA conducted a Case Management at which the licensee was cited for a deficiency in Health and Safety Code (HSC)1562.2(b)(1) for which the following plan of correction was agreed upon: Licensee to provide a written statement outlining the current status of the facility's foreclosure and/or proof of the properties currently being in escrow in Jenero Jefferson's name via the Closing Disclosure issued by the prospective lender no later than plan of correction due date 12/20/24.

As of today, CCL has not received the written statement from the licensee or proof of the properties currently being in escrow as outlined in the agreed upon plan of correction. Therefore, CCL is issuing a civil penalty for failure to correct deficiency HSC 1562.2(b)(1) for the period of 12/23/24 through 12/27/24 at $100 per day for a total of $500. The $100 per day civil penalty will continue to accrue until the deficiency is cleared.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver and a copy of this report was given

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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