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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 03/16/2023
Date Signed: 03/16/2023 04:51:53 PM

Document Has Been Signed on 03/16/2023 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
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:
03/16/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Rosilin Sadullah-CaregiverTIME COMPLETED:
04:55 PM
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Licensing Program Analyst(LPA) Dina Alviso is conducting a Post Licensing visit, on 3/16/23 at approximately 4:10pm and met with Rosilin Sadullah, Caregiver.

There are currently three clients in care today. The LPA toured the facility.

The LPA will be back at a later date to continue the Post Licensing visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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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