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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 05/02/2025
Date Signed: 05/02/2025 04:25:14 PM

Document Has Been Signed on 05/02/2025 04:25 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:
05/02/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:caregiverTIME VISIT/
INSPECTION COMPLETED:
04:39 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. LPA contacted licensee Jenero Jefferson by telephone. LPA advised licensee LPA was at facility to conduct: Annual inspection, Non-Compliance visit, and POC visit. Jenero informed LPA that facility has an Administrator now, he named I4 as being the new Admin and that he would be sending me all the paperwork "right now." LPA spoke to I4 and they advised they are not 21 years old yet. LPA called licensee back but received voicemail. LPA left voicemail indicating an Administrator is required to be at least 21 years old and have a current and active ARF Administrator certificate. I5 has completed course work but has yet to receive their certificate. LPA checked Administrator certificate Pending list but I5 not on it. LPA advised licensee of such and so there is actually not currently an Administrator for the facility. Deficiency cited on Annual inspection.

On 11/8/24, licensee Jenero Jefferson visited the Santa Rosa Regional Office and agreed to be placed on a non-compliance plan for a period of two years. Parties discussed multiple areas of concern including but not limited to the following:

· Licensee did not comply with a recent audit conducted by the Department


· Licensee did not notify licensing that all properties are in foreclosure.
· Licensee is having financial issues that have resulted in the regional center paying taxes that are the responsibility of the Licensee and staff have received delays in receiving their paychecks.


Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/02/2025
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Licensee was to ensure the following:
· Licensee to ensure all documents that were requested by the CCL auditor to be sent to CCL no later than Tuesday, November 12, 2024
· Licensee to provide a written statement outlining the current status of the foreclosure and what their plan is in the event that the facility is not able to maintain control of property no later than Tuesday, November 12, 2024.
· Licensee to review H&S code 1562.2 for ARF homes and 1569.686 for RCFE home and follow through with reporting requirements listed. Licensee to submit copies of required notifications and self-certification of compliance no later than Tuesday, November 12, 2024.

As of today 5/2/25, licensee did not fulfill or provide any of the aforementioned items to CCL.

LPA also conducted POC visit in conjunction with Non-Compliance visit. Civil penalties are being issued today.

On 2/21/25 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 2/14/25 through 2/21/2025 at $100 per day for a total of $4200. Also on 2/21/25 the licensee was issued 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 $4200, each, respectively.

As of today 5/2/25, 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 2/22/25 through 5/2/2025 at $100 per day for a total of $7000. The $100 per day civil penalty will continue to accrue until the deficiency is cleared. As of today 5/2/25, 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 2/22/25 through 5/2/2025 at $100 per day for a total of $7000 for each respective deficiency. The $100 per day civil penalty will continue to accrue until the deficiency is cleared.

Continued on 809C(2)...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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: 05/02/2025
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On 2/21/25 LPA conducted a Case Management visit at which the licensee was issued a civil penalty for failure to correct deficiencies of regulations 80078(a), 85064(e), 80075(b), 80026(h), 85072(b)(9). As of today 5/2/25, CCL has not received a plan of correction for deficiencies of regulations 880078(a), 85064(e), 80075(b), 80026(h), 85072(b)(9), respectively. Therefore, CCL is issuing a civil penalty for failure to correct deficiencies of regulations 80078(a), 85064(e), 80075(b), 80026(h), 85072(b)(9) for the period of 2/22/25 through 5/2/2025 at $100 per day for each respective deficiency for a total of $7000 for each respective deficiency. 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.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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