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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804038
Report Date: 02/13/2025
Date Signed: 02/13/2025 03:55:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240919145039
FACILITY NAME:FOREVER SARAHS ELDERLY CARE CORPFACILITY NUMBER:
496804038
ADMINISTRATOR:SAMPSON, JASMINEFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(310) 531-6049
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:4CENSUS: 3DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:CaregiverTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff did not seek timely medical care for client in care
Licensee does not have control of property
Staff are not following client’s medication orders
Clients needs are not being met
Staff mismanaged client finances
Staff did not ensure telephone services were available to residents in care
INVESTIGATION FINDINGS:
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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

Staff did not seek timely medical care for client in care and Clients needs are not being met. Complaint alleges that R1’s feet are swollen, and his toes are black. R1 has not worn his prescribed compression socks/support hose. R1 was diagnosed with diabetes after several days of swollen feet. Staff took several days to seek medical treatment for R1. During investigation, LPA received photographic evidence that R1’s feet were extremely swollen and had turned the colors black, purple, and red. This discoloration covered the entirety of R1’s toes and lower foot, extending up the entire outer side of their foot to their ankle. During investigation, LPA

Continued on 9099C...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 21-AS-20240919145039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/13/2025
NARRATIVE
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Continued from 9099...
**amended to remove confidential name**

interviewed staff that reported that they did not know about the condition of R1’s feet or that their feet were swollen, but that they did observe R1 to be walking differently than normal, seemingly in pain. Staff reported being aware that R1 needed to wear support socks, but that R1 had been wearing the wrong socks. This oversight was due to the residents' socks getting mixed up in the laundry bin. Per LPA’s interview with staff, all the residents’ dirty laundry would go in one basket and the socks would get mixed up, so R1 would end up wearing the wrong socks, not compression socks. Other staff informed LPA that they didn't know R1 needed to wear special compression socks. Additionally, LPA review of R1’s Individual Program Plan shows TED hoses listed as a current medication. During investigation, LPA reviewed medical provider telehealth notes that indicate on 9/10/24 R1 had swelling of the feet for about 2 weeks, per caregiver report, and provider observed R1’s feet to be very red and purple. Notes show medical provider determined that R1 needed to be seen immediately either at the Emergency Room or later that afternoon with medical care provider due to the observed condition of R1’s feet and ankles. Additionally, LPA reviewed medical provider notes for R2. Notes indicate that caregiver reported that R2 has had a sore throat and Upper Respiratory Infection symptoms for weeks before medical provider visit, notes also show that R2 was determined to have a pain assessment score of 6 by medical provider during visit. Based on LPA’s interview and photographic evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Licensee does not have control of property Complaint alleges that licensee does not have control of property. The Santa Rosa Regional office learned that the property where the facility is located is in foreclosure and has requested that the Licensee show proof of control of property on multiple occasions including but not limited to the Office Meeting conducted 11/8/2024 and the Case Management inspection conducted 12/19/2024 but Licensee has failed to provide proof to date. Based on LPA’s review of documents and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Continued on 9099C(2)...

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
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 21-AS-20240919145039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/13/2025
NARRATIVE
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Continued from 9099C...

Staff are not following client’s medication orders. During investigation LPA reviewed medical provider progress notes dated 9/11/24 for R2. Notes indicate R2 received extra 5mg dose of Warfarin by mistake. Additionally, report notes that R2 was given 15mg of Warfarin on 9/2/24, 9/3/24, and 9/4/24 by mistake. During investigation, LPA reviewed medical provider after summary visit for R1 from 9/10/24. Visit Summary has new orders for R1 that include applying Tubigrip in the A.M. and to remove at bedtime. LPA has visited facility more than four [4] times between the dates of 9/19/24 – 1/3/25 during business hours and never once observed R1 to be wearing Tubigrip. Based on LPA’s review of documents, observation, and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Staff mismanaged client finances. Complaint alleges staff mismanaged client finances. On 9/25/24 LPA reviewed residents’’ P&I monies. Upon review, Administrator reported that she holds the cards for all the residents. She will pay for items herself and then withdraw monies to reimburse herself. Furthermore, record of resident purchases did not have accompanying receipts present. Cash on hand did not match record of purchases. Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Staff did not ensure telephone services were available to residents in care. Complaint alleges staff did not ensure telephone services were available to residents in care. On 9/16/24 while LPA was present at the facility LPA in over the phone. She explained she was in Santa Rosa but in a meeting and would be at the facility soon. LPA called phone number 707-526-1808 which is the facility landline. LPA observed landline to ring but caregiver did not answer. LPA observed caregiver walk right past ringing phone in kitchen, walk

Continued on 9099C(3)...

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
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 21-AS-20240919145039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/13/2025
NARRATIVE
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Continued from 9099C(2)

down hall and go into another room. All present residents were in the living room. Landline was never answered. Today, LPA observed phone line and wifi modum to not be working. LPA tried to place out going call and could not. LPA called facility number and it goes straight to an automated voicemail message that states the mailbox is full and cannot receive messages. Based on LPA’s observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

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
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240919145039

FACILITY NAME:FOREVER SARAHS ELDERLY CARE CORPFACILITY NUMBER:
496804038
ADMINISTRATOR:SAMPSON, JASMINEFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(310) 531-6049
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:4CENSUS: 3DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:CaregiverTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Clients are not provided activities
INVESTIGATION FINDINGS:
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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

Clients are not provided activities. Complaint alleges clients are not provided activities. LPA has visited facility seven [7] times over the course of nine [9] months. Each time LPA has observed activities present such as puzzles and games. On two [2] visits LPA observed residents actively using puzzles. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with caregiver and a copy of this report was given.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 21-AS-20240919145039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met by licensee as evidenced by: Based on LPA record review and photographic evidence, the licensee did not
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Facility licensee to contact Sonoma County ombudsman for closest date of the next of personal rights training course and report date to LPA by plan of correction due date. Both facility licensee and all facility staff to complete personal rights training course with Sonoma
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comply with the section cited above in that R1 and R2 did not receive timely medical care and some of their care needs were not met, which poses an immediate health, safety or personal rights risk.
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County Ombudsman on the date reported to LPA. Facility to submit proof of training completed to CCL no later than 3/14/25.
Type A
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Section Cited
HSC
1562.2(b)(1)
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(b) Licensee of an ARF shall inform the city & county in which the facility is located, the department, all residents, and, if applicable, their legal representatives, in writing, within 2 business days…of any of the following events, or knowledge of the event:
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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 2/14/25
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 (1) A notice of default, notice of trustee’s sale or any other indication of foreclosure is issued on the property. This requirement is not met by licensee as evidenced by: Based on record review the licensee did not comply with the section cited above by not ensuring that CCL was notified when homes went into foreclosure which poses an immediate health, safety, or personal rights risk
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 21-AS-20240919145039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met by licensee as evidenced by: Based on LPA record
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Licensee to submit plan to conduct medication training for all staff by plan of correction due date. Facility to conduct medication training for all staff for a duration of no less than 1 hour by no later than 2/21/25. Facility to submit training log with hour, duration, date
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review the licensee did not comply with the section cited above in that R1 and R2 received incorrect dose of medication or didn’t receive medication period, which poses an immediate health, safety, or personal rights risk.
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of attendance, trainer’s name, and staff attendees no later than 2/21/25.
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Section Cited
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care…This requirement is not met by licensee as evidenced by:
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Facility to submit current, up-to-date reconciled cash resources records, including all expenditure receipts, for all residents’ cash resources by plan of correction due date.
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Based on LPA record review and observation, the licensee did not comply with the section cited above in that facility record of residents’ purchases did not have accompanying receipts present. Additionally, cash on hand did not match record of purchases, which poses an immediate health, safety, or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 21-AS-20240919145039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
85072(b)(9)
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85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights. (9) To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients
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Facility to submit LIC9098 ensuring that facility phone will be answered timely whenever possible, the facility’s voicemail to be frequently checked such that it has the capacity to receive voicemails at all times, and that all calls for residents or
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and do not restrict availability of the telephone during emergencies. This requirement is not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed landline/facility telephone to ring, but caregiver did not answer phone despite caregiver not being engaged with or providing care for residents, which poses an immediate health, safety or personal rights risk.
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regarding residents will be returned within 24 hours of receipt, by plan of correction due date. Facility to also submit proof that telephone and wifi bill are current.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8