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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:06:01 PM

Document Has Been Signed on 05/30/2025 03:06 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:
05/30/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC case management visit and was greeted by caregiver. LPA called licensee to advise purpose of LPA visit, but licensee did not answer LPA phone call. LPA left voicemail for licensee.

On 5/2/25 LPA conducted the annual inspection, citations and civil penalties were issued. As of today, CCL has not received plans of corrections for citations issued on 5/2/25 for deficiencies of regulations: 85064(b), 80075(f), 80069(b), 80075(k)(1), 85088(c)(4)(B), 80077.3(a)(3)(C), 80066(e), 80087(g). These citations are being re-issued today for failure to correct, please see 809Ds.

On 5/2/25 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 2/22/25 through 5/2/2025 at $100 per day for a total of $7000. Also on 5/2/25 the licensee was issued a civil penalty for failure to correct deficiencies 80062(a)(1) and 80076(a)(1) for the period of 2/22/25 through 5/2/2025 at $100 per day for a total of $7000, each, respectively.

As of today 5/30/25, 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 5/3/25 through 5/30/2025 at $100 per day for a total of $2800. The $100 per day civil penalty will continue to accrue until the deficiency is cleared. As of today 5/30/25, 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 5/3/25 through 5/30/2025 at $100 per day for a total of $2800 for each respective deficiency. The $100 per day civil penalty will continue to accrue until the deficiency is cleared.

Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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 8
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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Document Has Been Signed on 05/30/2025 03:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2025 at 01:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
80087(g)

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80087(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Facility to submit LIC9098 self- certifying they will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients by POC due date
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Based on LPA observation, the licensee did not comply with the section cited above in that master bedroom unlocked. bleach and laundry soap present in bath of master bedroom accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/02/2025
Section Cited
CCR80066(e)

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80066(e) All personnel records shall be maintained at the facility site.

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Facility to submit TB clearance for S1 and S3 and Health Screen for S2 by plan of corrections due date.
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Based on LPA observation and record review, the licensee did not comply with the section cited above in that S1 and S3 did not have TB clearance, S2 did not have Health Screen, which poses a potential health, safety or personal rights risk to persons in care
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 06/10/2025 04:19 PM


Created By: Christi Coppo On 05/30/2025 at 01:07 PM
Link to Parent Document Below:
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
80077.3(a)(3)(C)

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80077.3(a)(3)(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift...

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Facility to conduct disaster drills on each shift for all staff by plan of correction due date. Documentation of completed drills to be submitted by plan of correction due date.
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Based on LPA record review, the licensee did not comply with the section cited above in that facility’s last quarterly disaster drills were not executed and/or documented which poses a potential health, safety or personal rights risk to persons in care.
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Type A
06/02/2025
Section Cited
CCR85088(c)(4)(B)

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85088(c) The licensee shall ensure provision to each client of the following...(B) The use of common towels and washcloths shall be prohibited.

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Facility to purchase/supply paper towels and ensure common towels. Receipt for paper towels in a quantity that is enough for all residents and staff to use to be submitted by plan of correction due date.
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**amended to assess civil penalty with correct assessment dates of 6/3/25 through 6/10/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2025 03:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2025 at 01:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
80075(k)(1)

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80075(k) The following requirements shall apply to medications...centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible...This requirement is not met as evidenced by:
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Facility to submit LIC9098 self-certifying that medication shall be kept in a safe and locked place that is not accessible to residents
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Based on LPA observation, the licensee did not comply with the section cited above in that Medication is stored in a closet, LPA found door unlocked and medication accessible to residents. Medication tablet found in facility unlocked office in bubble pack accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/02/2025
Section Cited
CCR80069(b)

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80069(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

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Facility to submit plan to have R1's current medical assessment completed. Current medical assessment for R1 by no later than 6/2/25.
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Based on LPA observation and record review, the licensee did not comply with the section cited above inthat R1 did not have a medical assessment on file, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/30/2025 03:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2025 at 01:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
80075(f)

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80075(f)Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
This requirement is not met by licensee as evidenced by:
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Facility to submit plan to have S1 and S3 complete1st Aid/CPR certification. Certification to be completed no later than 5/12/25.
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Based on LPA record review, the licensee did not comply with the section cited above in that S1 and S3 1st Aid/CPR exp 4/21/25, which poses an immediate health, safety or personal rights risk to persons in care.

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Type A
06/02/2025
Section Cited
CCR85064(b)

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85064(b) All adult residential facilities shall have a qualified and currently certified administrator.

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Facility to submit required documents for individual that will be the Administrator by plan of correction due date. Documents to include: LIC215, LIC500, LIC308, LIC501, detailed employment/education history,
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Based on LPA observation and interview, the licensee did not comply with the section cited above inthat facility does not currently have an Administrator which poses an immediate health, safety or personal rights risk to persons in care.
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copy of Admin certificate, and board resolution from the corporation
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
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: 05/30/2025
NARRATIVE
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Continued from 809...

On 5/2/25 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) 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. As of today 5/30/25, 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 5/3/25 through 5/30/2025 at $100 per day for each respective deficiency for a total of $2800 for each respective deficiency. The $100 per day civil penalty will continue to accrue until the deficiency is cleared.

Additionally, LPA also conducted Health and Safety check visit in conjunction with POC visit today. On Friday, May 23, 2025, CCL was notified that the facility’s garbage cans were taken and the facility’s garbage service was shut off. LPA was advised that the garbage cans had been reclaimed about 2.5 weeks ago. LPA verified with Santa Rosa garbage company, Recology, that the mailing address for garbage billing is the same as the facility’s physical address. Per Recology customer service representative (CSR), the facility was mailed at least 3 shut off notices: one at 90 days past due, one at 150 days past due, and one final 7 day notice. LPA verified with CSR’s supervisor that the garbage service was shut off in November of 2024 due to non-payment. Per CSR’s supervisor, Recology had been trying for some time since then to collect the cans, but was unsuccessful until April 18, 2025. On April 18, 2025 the cans were reclaimed by Recology (deficiency cited, see 809D). LPA verified that Recology picks up garbage, recycling, and green waste, all three [3]. Also, LPA verified that there is no other garbage service offered in Santa Rosa other than Recology. As of today, 5/30/25 LPA was advised that the garbage cans were retuned to the facility. However, LPA unable to reach licensee to confirm payment was made and account turned back on.

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: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/30/2025 03:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/30/2025 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
80063(a)

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80063 Accountability

(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.
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Facility to submit LIC9098 self-certifying that all utility services including garbage services will be maintained, paid current, and operational at all times, by plan of correction due date.
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This requirement not met by licensee as evidenced by: Based on LPA interview garbage service was shut off due to non-payment November of 2024, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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