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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:17:19 PM

Document Has Been Signed on 12/19/2024 04:17 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: DATE:
12/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:06 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to conduct a case management visit and was greeted by caregiver. Licensee Jenero Jefferson was not available to come to the facility, but was reached by telephone.

On 11/8/24 licensee attended Santa Rosa regional office meeting at which they were cited for a deficiency in Health and Safety Code (HSC)1562.2(b)(1) for which the following plan of correction was agreed upon: 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 POC due date 11/12/2024. As of today, CCL has not received the written statement from the licensee. LPM reached licensee by phone to advise that CCL will be re-citing HSC 1562.2(b)(1) on the attached 809D.


Additionally, per LPM phone conversation with licensee, change of property ownership of this facility and Forever Sarah's Anna Home is currently in escrow. Licensee will submit documents showing proof of escrow to CCL by no later than 12/20/24.

Lastly, Licensee was to ensure all documents that were requested by the CCL auditor to be sent to CCL no later than Tuesday, November 12, 2024. As of today, all documents requested to be sent to CCL auditor have not been received. Licensee to provide all documents to CCL no later than Monday, December 23,2024

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: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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Document Has Been Signed on 12/19/2024 04:17 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/19/2024 at 03:08 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: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2024
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: (1) A notice of default, notice of trustee’s sale
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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 currenty being in escorw in Jenero Jefferson's name via the Closing Disclosure issued by the prospective lender no later than POC due date 12/20/24
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or any other indication of foreclosure is issued on the property. Requirement is not met 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 a 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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