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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:51:34 PM

Document Has Been Signed on 02/13/2025 04:51 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: 3DATE:
02/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:08 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:06 PM
NARRATIVE
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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

As of 12/18/24 facility has not had an administrator (deficiency cited, see 809D). On 1/3/25 LPA conducted POC visit at facility and observed hospital discharge papers to be posted in the kitchen in plain sight for all visitors and residents to see. Hospital discharge papers for R1 and R2 were both posted in the kitchen (deficiency cited, see 809D). CCL did not receive an Incident Report to report either hospital visit referenced in the discharge papers posted in the kitchen. CCL has only ever received one Incident Report from this facility since its license was issued (deficiency cited, see 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: 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.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 02/13/2025 04:51 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/13/2025 at 04:10 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: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
85064(b)

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85064 Administrator Qualifications and Duties (b) All adult residential facilities shall have a certified administrator. This requirement is not met by licensee as evidenced by: Based on LPA interview and observation, the licensee did not comply with the section cited above in
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Facility to submit candidate for Administrator and all required paperwork: LIC215, LIC500, LIC308, LIC501, detailed employment/education history, copy of current and active Administrator certificate, and board resolution by plan of correction due date.
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that 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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Type A
02/14/2025
Section Cited
CCR80061(b)(1)(D)

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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information
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Facility to submit plan to conduct reporting requirements training for all staff including licensee, by plan of correction due date. Facility to conduct reporting requirements training for a duration of no less than 1 hour no later than 2/21/25.
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specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (D) Any injury to any client which requires medical treatment. This requirement is not met by licensee as evidenced by: Based on LPA record review and observation, the licensee did not comply with the section cited above in that facility did not submit incident reports to CCL for residents after events which required residents to receive medical care, which poses an immediate health, safety, or personal rights risk to persons in care.
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Facility to submit training log with hour duration, date of attendance, trainer’s name, and staff attendees no later than 2/21/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/13/2025 04:51 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/13/2025 at 04:25 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: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
80070(c)

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80070 Client Records (c) All information and records obtained from or regarding clients shall be confidential.
This requirement is not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section
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Facility to submit plan to conduct resident records keeping training for all staff including licensee, by plan of correction due date. Facility to conduct resident records keeping training for a duration of no less than 2 hours no later than 2/21/25.
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 cited above in that facility did not keep resident hospital discharge papers confidential, which poses an immediate health, safety, or personal rights risk to persons in care.
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Facility to submit training log with hour duration, date of attendance, trainer’s name, and staff attendees no later than 2/21/25.

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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: 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


LIC809 (FAS) - (06/04)
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