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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:22:19 PM

Document Has Been Signed on 02/13/2025 04:22 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: 3DATE:
02/13/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:59 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:22 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings for the above allegation 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. LPA sent text to licensee to advise purpose of visit

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. On 1/3/25 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 12/28/24 through 1/3/25 at $100 per day for a total of $700.Also on 1/3/25, the licensee was issued civil penalties for failure to correct deficiencies of regulations 80062(a)(1) and 80076(a)(1), for the period of 12/31/24 through 1/3/2025 at $100 per day for a total of $400 each, respectively.

As of today 2/13/25, CCL has not received a plan of correction for deficiency of Health and safety Code (HSC) 1562.2(b)(1). Therefore, CCL is issuing a civil penalty for failure to correct deficiency of HSC 1562.2(b)(1) for the period of 1/4/25 through 2/13/2025 at $100 per day for a total of $4200. The $100 per day civil penalty will continue to accrue until the deficiency is cleared. As of today 2/13/25, CCL has not received a plan of correction for deficiencies of regulations 80062(a)(1) and 80076(a)(1), respectively. Therefore, CCL is issuing a civil penalty for failure to correct deficiencies 80062(a)(1) and 80076(a)(1) for the period of 1/4/25 through 2/13/2025 at $100 per day for a total of $4200, each respectively. 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: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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