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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 12/27/2024
Date Signed: 12/27/2024 03:12:23 PM

Document Has Been Signed on 12/27/2024 03:12 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:
12/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:32 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a 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.

On 11/08/24 CCL delivered to licensee substantiated findings of complaint 21-AS-20240605093000 and citations were issued for deficiencies of California Code of Regulations 80062(a)(1) and 80076(a)(1), respectively. The following plan of correction was issued for deficiency of regulation 80062(a)(1): Facility to submit all documents that were originally requested by the CCL auditor no later than plan of correction due date, 11/12/2024. The following plan of correction was issued for deficiency of regulation 80076(a)(1) ): Facility to submit a written plan that indicates how facility will ensure clients have access to the quantity and quality of food required by regulation. Additionally, the facility is to provide a menu for the upcoming week along with grocery receipts showing food items have been purchased related to the menu no later than plan of correction due date, 11/12/2024.

As of today, CCL has not received any documents from licensee fulfilling the plans of correction for deficiency of regulation 80062(a)(1) or 80076(a)(1). Therefore, the deficiencies are being cited today on the attached 809D.

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: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 12/27/2024 03:12 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/27/2024 at 02:41 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: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2024
Section Cited
CCR
80062(a)(1)

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Finances: (a) The licensee shall meet the following financial requirements: (1) Development and maintenance of a financial plan which ensures resources necessary meet operating costs for care and supervision of clients. This requirement is not met as evidenced by:
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Facility to submit all documents that were originally requested by the CCL auditor no later than plan of correction due date due date, 12/30/2024.
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Based on record review and interviews, the licensee did not comply with the section cited above by not ensuring that operating costs such as taxes being paid, and staff being paid timely which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/30/2024
Section Cited
CCR80076(a)(1)

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Food Services:(a)(1) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan...All food shall be
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Facility to submit a written plan that indicates how facility will ensure clients have access to the quantity and quality of food required by regulation. Additionally, the facility is to provide a menu for the upcoming week along with grocery receipts showing food items have been
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selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on LPA observation and interviews, the licensee did not comply with the section cited above by not always ensuring the quantity of food required by regulation, which poses an immediate health, safety or personal rights risk to persons in care.
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purchased related to the menu no later than plan of correction due date, 12/30/24.
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: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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