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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:24:15 PM

Document Has Been Signed on 04/07/2023 04:24 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:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Sarah Ramirez-Direct Support ProfessionalTIME COMPLETED:
04:40 PM
NARRATIVE
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 Licensing Program Analyst(LPA) Alviso arrived to the facility to conduct a Required 1-Year visit, on 4/7/23 at approximately 10:50am, and met with DSP Sarah Ramrez. LPA asked staff to contact Lead DSP Jasmine Sampson and notify her that the LPA was at the home to conduct a visit. LPA had planned to continue the Post Licensing visit of 3/16 but instead will complete the now available Required 1-Year inspection.

Facility is fire cleared for four ambulatory clients. The LPA toured the facility with staff Sarah. All rooms were furnished and had sufficient lighting. There was a sufficient supply of food. There was a sufficient supply of hygiene products, cleaners, and paper products. There are three(3) full bathrooms for client use.

The fire extinguisher, one(1), was serviced and tagged as required-dated 3/24/23. The medications were locked and inaccessible to the clients in care. Cleaners/toxins were locked up and inaccessible to clients in care. The smoke alarms (9 checked) were all working properly during the visit. Hot water was checked at 112.6F which is within regulation.

LPA observed that the facility had sanitizer available for use in the facility, and there was a sufficient supply of personal protective equipment(PPE) for staff, and others use as needed.

The LPA reviewed four(4) out of four(4) client files. Client files were found to be complete. LPA observed that client cash resources are not co-mingled and records are maintained as required.
Continued on LIC809C....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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Document Has Been Signed on 04/07/2023 04:24 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/07/2023 at 02:21 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's(observations, and record reviews, the licensee did not comply with the section cited above in [2] out of [4] direct care staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2023
Plan of Correction
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Licensee to ensure that staff S4 & S5 obtain First Aid Certification as required by regulation. Submit proof of staff's current active certification, copies of First Aid Cards showing names & dates, no later than 4/11/23, Plan of correction(POC) due 4/8/23.
Type A
Section Cited
CCR
80087(c)
80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during the facility tour with staff Sarah, the licensee did not comply with the section cited above in [1] out of [2] exit doors out of the facility, LPA obtained photos, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2023
Plan of Correction
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Licensee to ensure that the back exit door, which leads onto the deck , is free and clear of obstruction(s) that can make it unsafe for clients trying to exit out this door, in an emergency andor at any time. Submit photos of this exit door having been cleared and free of obstructions. POC due 4/8/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2023 04:24 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/07/2023 at 02:21 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observatios during record reviews the licensee did not comply with the section cited above in [1] out of [4] staff. S4 has a clearance with a Home Aid Agency but is not associated to Forever Sarah's which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2023
Plan of Correction
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Facility is to submit a criminal record transfer request, with all other required forms per regulation to have staff (S4) associated to the facility; Licensee may use Guardian system and associate S4 on their own, and submit proof of tS4 now associated to Forever Sarahs Elderly Care Corp. Licensee to ensure all staff are cleared and associated as required by regulations at all times. POC due 4/8/23.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's (observation and record reviews the licensee did not comply with the section cited above in {2] out of [6] staff files, (S1 & S2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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Licensee to ensure that all staff files are available on-site for review as required. Staff files are to be complete,and maintained per regulations. Licensee to ensure that S1 and S2 have files/copies of required staff documents on-site at Forever Sarah's facility site. Licensee to submit written self certification that this has been done and the staff files are available for review as required. POC due 4/14/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CORP
FACILITY NUMBER: 496804038
VISIT DATE: 04/07/2023
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LPA was able to review four(4) out of six(6) staff files, the Administrator Janero J., and Lead DSP Jasmine S. had no files on-site at the facility during the LPA's inspection and per LPA's file reviews. This deficiency will be cited, Personnel Records 80066(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee, see LIC809D.

Two(2) out of four(4) staff have current first aid training, including CPR. Two(2) staff have no current first aid certification as required per LPA's file review. This deficiency will be cited, 80075(f) Health- Related Services- Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross, see LIC809D.

One(1) out of four(4) staff are cleared and associated as required. LPA contacted Licensing and identified that staff(S4) has a clearance but is not associated to ato the care home, Forever Sarah's. This deficiency will be cited, 80019(e)(3) Criminal Record Clearance-All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) , see LIC809D. There is an immediate civil penalty fine assessed today in the amount of $100, see LIC421BG.

The exit door leading out to the deck had an outside rug pulled up, causing it to bunch up, along with some patio chairs which are blocking part of the area to exit out. Licensee to ensure the exit door area is free and clear of outside obstruction(s) that can make it unsafe for clients trying to exit out this door, in an emergency and/or at any time. This deficiency will be cited, 80087 (c)Buildings and Grounds All outdoor and indoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard shall be kept free of obstruction.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CORP
FACILITY NUMBER: 496804038
VISIT DATE: 04/07/2023
NARRATIVE
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LPA requested the following updated forms to be submitted to Community Care Licensing by 04/27/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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