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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:56:43 PM

Document Has Been Signed on 05/17/2022 12:56 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FOREVER SARAHS ELDERLY CARE CORPFACILITY NUMBER:
496804038
ADMINISTRATOR:JEFFERSON, JENEROFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(310) 531-6049
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Jenero JeffersonTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Pre-Licensing Inspection and met with Administrator, Jenero Jefferson. LPA was initially greeted by staff, administrator arrived later

LPA toured facility with staff. Facility is a one story building with 4 client bedrooms. During the inspection 3 out of 4 clients were attending a day program away from the facility. At the facility LPA observed 1 staff and 1 client. Facility was clean and in good repair. LPA measured water temperature at 114.2 and 116.0 degrees F at two sinks available to clients which is within regulation. Client bedrooms were clean and had the appropriate furnishings. Bedrooms are personalized to suit each client's interests. Medications are stored in a locked medication closet. LPA and staff went over the medication administration record and medication pass for the morning of 05/17.

A fire extinguisher was observed in the kitchen, last inspected on 11/09/2021. Disaster drills are performed quarterly, last one was performed in January. Facility has an approved fire clearance for 4 ambulatory clients. Sufficient perishable and non-perishable food was observed in the kitchen. Sharps and cleaning supplies are kept in a locked closet in the living room. Smoke detectors and CO detectors were tested and operational.

LPA toured the backyard and observed scattered debris throughout. LPA provided guidance to make the outdoor area comfortable and furnished for outdoor use. LPA reviewed 2 staff records, both contained current CPR/First Aid training.

Component III reviewed with administrator. Exit interview conducted with administrator. LPA unable to print, report emailed to administrator. LPA will notify application unit so application process may proceed.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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