<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 01/03/2025
Date Signed: 01/03/2025 03:22:51 PM

Document Has Been Signed on 01/03/2025 03:22 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:
01/03/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:37 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 and was not available by phone, so LPA left a voicemail message. LIcensee Jenero sent a text to LPA indicating they were not able to speak due to illness.

On 12/27/24 LPA conducted a Case Management visit at which the licensee was issued 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.

As of today 1/3/25, CCL has not received the plan of correction for deficiency HSC 1562.2(b)(1): a 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 12/28/24 through 1/3/2025 at $100 per day for a total of $700. The $100 per day civil penalty will continue to accrue until the deficiency is cleared.

On 11/08/24 CCL delivered to licensee substantiated findings of complaint 21-AS-20240605093000 and citations were issued for deficiencies of California Code of Regulations 80062(a)(1) and 80076(a)(1), respectively. The following plan of correction was issued for deficiency of regulation 80062(a)(1): Facility to submit all documents that were originally requested by the CCL auditor no later than plan of correction due date, 11/12/2024. The following plan of correction was issued for deficiency of regulation 80076(a)(1) ): 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 have been purchased related to the menu no later than plan of correction due date, 11/12/2024.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CORP
FACILITY NUMBER: 496804038
VISIT DATE: 01/03/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809...

As of 12/27/24, CCL had not received any documents from licensee fulfilling the plans of correction for deficiency of regulation 80062(a)(1) or deficiency of regulation 80076(a)(1) that were due by plan of correction due date 11/12/24. So, on 12/27/24 the deficiencies were cited and the following plans of correction were due by 12/30/24: facility to submit all documents that were originally requested by the CCL auditor no later than plan of correction due date due date 12/30/2024 and 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 have been purchased related to the menu no later than plan of correction due date 12/30/24.

As of today 1/3/25, CCL has not received the plan of correction for deficiency of regulation 80062(a)(1) or for deficiency of regulation 80076(a)(1). Therefore, CCL is issuing respective civil penalties for failure to correct these deficiencies for the period of 12/31/24 through 1/3/2025 at $100 per day for a total of $400 each. The $100 per day civil penalty will continue to accrue until the deficiency is cleared.

During LPA visit, resident R1 was speaking to LPA and advised that they still have a rash. LPA and caregiver spoke about resident's rash and R1 is still experiencing discomfort. LPA asked who is attending to residents' doctor appointments, either making the appointments or taking them to the appointments when needed. Caregiver advised that the Administrator was the one to do that; however, now that there is no Administrator no one is taking them.

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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2