<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 05/21/2024
Date Signed: 05/21/2024 05:15:02 PM

Document Has Been Signed on 05/21/2024 05:15 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:		SAMPSON, JASMINEFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(310) 531-6049
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: 4DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:29 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Christi Coppo and Jacqueline Macias arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. LPA contacted Administrator who was out of town but had limited availability by phone. Administrator gave caregiver permission to sign report. Facility contact information was reviewed.


At approximately 9:30am, LPAs and caregiver toured the building and grounds. The facility was found to be at a comfortable temperature. LPAs and caregiver observed the kitchen sink leaking and water pooling on the floor underneath. LPAs observed a water soaked towel underneath a basin that was placed under the sink to collect the leaking water. Space for dishwasher observed to have black film, brown staining, and green film and rodent poison pack (deficiency cited, see 809D). LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was not found to be stored in a safe manner with open items covered. Cereal bags were wide open, not labeled with opened date. Tortillas not stored in an air tight container. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured at 127 degrees F which is not within the allowable range of 105 to 120 degrees F. (deficiency cited, see 809D). LPA observed common towels. Caregiver explained behaviors around towels, residents prefer towels. LPA explained the regulation and that the facility must ensure no common towel use. LPA suggested using paper towels.

At approximately 10:30am LPAs and caregiver observed rodent traps in the garage, with peanut butter lure present. LPAs observed rodent droppings near traps and on shelving (deficiency cited, see 809D). LPA observed freezer in garage to have several jugs of frozen milk with expired best if used by date. Loaf of bread and a pack of hot dog buns had ice crystals present throughout the bag.

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809...

At approximately 10:45am LPAs and caregiver observed cleaning supplies, toxins (ammonia and alcohol), and toiletries stored with food in locked hall closet. LPAs advised caregiver that cleaning supplies and toxins must be stored separately from food items (deficiency cited, see 809D). LPAs advised caregiver that food cannot be locked up and inaccessible to residents. Snacks must be available for residents at all times. LPAs advised caregiver to confirm with Admin if facility wants to maintain locked food pantry, if so, a waiver must be requested from CCL.

At approximately 11:30am, LPAs and caregiver observed the bottom step leading to wrap around deck to be broken and deck to be unstable. The wood of the wrap around deck makes cracking sounds when bearing weight.

Fire extinguishers were last inspected 3/19/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 1/4/2024.

At approximately 1:00pm LPA conducted a review of four [4] resident records. R1, R3, R4 did not have Physician Reports on file (deficiency cited, see 809D). R1, R2, R3, and R4 all did not have Appraisal Needs and Services Plans (R3 had one but it was dated 2016) (deficiency cited, see 809D). R1, R2, and R3 did not have Admissions Agreements available (deficiency cited, see 809D).

At approximately 2:15pm LPA conducted review of five [5] staff records. S1 and S3 did not have Health Screens (deficiency cited, see 809D).

At approximately 2:45pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. R1 had two prescriptions bubble packs not found on Centrally Stored Medication Log. Medications are bubble packs of Buspirone HCL 5 mg and Calcium Carbonate 600 mg (deficiency cited, see 809D).

Continued on 809C(2)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809C...

Jasmine Sampson Administrator Certificate 6047455740 expires 10/18/2024. Facility licensing fees due, LPAs gave caregiver LIS printout with PIN and amount due.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Surety Bond

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. LPA called Administrator to offer to conduct exit interview via telephone, but Admin declined and will contact LPA will any questions. A copy of this report was given to caregiver.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 05/21/2024 05:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/21/2024 at 03:23 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: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver observation and record review, the licensee did not comply with the section cited above in that R1 had 2 medications in bubble packs not found on Centrally Stored Medication Log. Medications are bubble pack of Buspirone HCL 5 mg and Calcium Carbonate 600 mg, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2024
Plan of Correction
1
2
3
4
Facility to submit plan of how they will properly record and store medications and log them on the Centrally Stored Medication Log. Facility to submit plan by plan of correction due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 05/21/2024 05:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/21/2024 at 03:23 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: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver's observation, the licensee did not comply with the section cited above in that the kitchen sink is leaking, water pooling on the floor underneath, water soaked towel underneath basin collecting the leaking water. Space for dishwasher observed to have black film, brown staining, and green film and rodent poison pack. Screen in the kitchen window is missing. Shower in the main bathroom has a broken curtain rod. Living room wall has a hole measuring to approximately 2' by 1', sheet rock exposed. Closet doors are removed from closet lying horizontally on their side blocking resident access to the closet. Carpet in bedroom 2 was ripped and had exposed foam liner and stained with yellowish and green substance. Steps to the backyard are in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
1
2
3
4
While LPAs present, facility fixed/addressed the following items: leak in kitchen sink, water pooling on the floor, water soaked towel, cleaned black film, brown staining, and green film in dishwasher space and removed rodent poison pack. Facility to repair the following items by plan of correction due date: screen in the kitchen window, broken curtain rod in hallway bathroom, hole in living room wall, and steps to the backyard wrap around deck.Facility to submit pictures of fixed items to CCL by plan of correction due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregivers observation, the licensee did not comply with the section cited above in that the temperature of water was 127 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
1
2
3
4
Facility to submit water temperature log for a duration of two weeks to CCL by plan of correction due date. Water log to depict a temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). Log to include 2 temperatures per day one in the morning and one at night.
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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 05/21/2024 05:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/21/2024 at 03:23 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: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver observation and record review, the licensee did not comply with the section cited above in that S1 and S3 did not have Health Screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL photos of health screens for S1 and S3, including TB clearance by plan of correction due date.
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver observation the licensee did not comply with the section cited above in that cleaning supplies, toxins (ammonia and alcohol), and toiletries were stored with food in locked hall closet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2024
Plan of Correction
1
2
3
4
While LPAs present, caregiver separated cleaning supplies and toxins from food. Deficiency cleared.
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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 05/21/2024 05:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/21/2024 at 03:23 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: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver observation, the licensee did not comply with the section cited above in that rodent traps observed in the garage, with peanut butter lure present, and rodent droppings observed near traps and on shelving which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL copy of Pest/Rodent Exterminator work order and paid invoice by plan of correction due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver observation and record review, the licensee did not comply with the section cited above in that R1, R2, and R3 did not have Admissions Agreements available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL photo of fully executed Admissions Agreement for R1, R2, and R3 by plan of correction due date.
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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 05/21/2024 05:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/21/2024 at 03:23 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: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver observation and record review, the licensee did not comply with the section cited above in that R1, R3, R4 did not have Physician Reports on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL photos of Physician Reports for R1, R3, and R4 by plan of correction due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 05/21/2024 05:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/21/2024 at 04:21 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: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)

80068.3(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and caregiver observation and record review, the licensee did not comply with the section cited above in that R1, R2, R3, and R4 all did not have Appraisal Needs and Services Plans (R3 had one but it was dated 2016), which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 06/11/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL photos of current Appraisal Needs and Services Plans for R1, R2, R3 and R4 by plan of correction due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 12 of 12