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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:18:54 PM

Document Has Been Signed on 02/21/2025 03:18 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: 2DATE:
02/21/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:caregiverTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC case management 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. LPA sent text to licensee to advise purpose of visit. Licensee responded to text and asked LPA to "please let me know what needs to be corrected." LPA responded to text message stating "call me and I will explain all the corrections or you can read the reports and citations I left here on 2/13/25 and that if you'd like to call Ill be here for about another half an hour so." LPA then called Jenero again and this time could leave a voicemail.

On 2/13/25 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 1/4/25 through 2/13/2025 at $100 per day for a total of $4200. Also on 2/13/25 the licensee was issued 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.

As of today 2/21/25, 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 2/14/25 through 2/21/2025 at $100 per day for a total of $800. The $100 per day civil penalty will continue to accrue until the deficiency is cleared. As of today 2/21/25, 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 2/14/25 through 2/21/2025 at $100 per day for a total of $800 for each respective deficiency. The $100 per day civil penalty will continue to accrue until the deficiency is cleared.




Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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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: 02/21/2025
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On 2/13/25 LPA delivered complaint findings for complaint 21-AS-20240906084230 and issued citations for deficiencies of regulations: 80078(a) and 85064(e) with plans of correction for both deficiencies due on 2/14/25. As of today 2/21/25, CCL has not received a plan of correction for deficiencies of regulations: 80078(a) and 85064(e). Therefore, CCL is issuing a civil penalty for failure to correct deficiencies of regulations 80078(a) and 85064(e) for the period of 2/15/25 through 2/21/2025 at $100 per day for each respective deficiency for a total of $700 for each respective deficiency.

On 2/13/25 LPA delivered complaint findings for complaint 21-AS-20240919145039 and issued citations for deficiencies of regulations, 80075(b), 80026(h), and 85072(b)(9) with plans of correction for all three deficiencies due on 2/14/25. As of today 2/21/25, CCL has not received a plan of correction for deficiencies of regulations: 80075(b), 80026(h), and 85072(b)(9). Therefore, CCL is issuing a civil penalty for failure to correct deficiencies of regulations: 80075(b), 80026(h), and 85072(b)(9) for the period of 2/15/25 through 2/21/2025 at $100 per day for each respective deficiency for a total of $700 for each respective deficiency.

**also on this visit LPA amended complaint findings for allegation "Staff are not transporting residents to and from appointments" alleged in complaint 21-AS-20240906084230. The findings were changed from Substantiated to Unsubstantiated due to the residents actually making it their appointments, by way of caregivers' personal vehicles. Additionally, the related 9099D issued was also amended to remove deficiency 80074(c) that was issued as a result of the substantiated complaint finding for allegation "Staff are not transporting residents to and from appointments" alleged in complaint 21-AS-20240906084230.**

***also on this visit LPA amended the 9099C page of complaint findings for complaint 21-AS-20240919145039 to remove a confidential name**

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: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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