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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804038
Report Date: 02/21/2025
Date Signed: 02/21/2025 02:13:28 PM

Unsubstantiated


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
09/06/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240906084230
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: 2DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:CaregiverTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff are not transporting residents to and from appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to amended complaint 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 are not transporting residents to and from appointments. Complaint alleges there is never gas in the van to take clients to and from appointments. During investigation, LPA interviewed staff and received conflicting accounting of gas being in the van. Staff reported to LPA they had to use their own money to put gas in the facility van so that they could take residents to their appointments. Other staff report to LPA that the van always had gas because they timed the request for gas well before gas ran out. During

Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
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 2
Control Number 21-AS-20240906084230
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: 02/21/2025
NARRATIVE
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Continued from 9099...

investigation, LPA reviewed caregiver notes written on 8/3/24-9/12/24; however, dates of caregiver notes inconsistent, present for all days. Notes indicate on 8/3/24 the van had gas, on 9/10/24 gas was put into the facility van by caregiver but no note about the caregiver using their own money. On 12/19/24 LPA observed a full tank of gas in facility van. However, LPA observed tags on facility van to be expired as of September of 2024. Per interview with staff they had to use their own car to take the residents to the doctor due to facility van having expired tags. 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2