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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 04/15/2022
Date Signed: 04/15/2022 11:16:49 AM

Document Has Been Signed on 04/15/2022 11:16 AM - 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:
496804043
ADMINISTRATOR:MCDONALD, ALYSSAFACILITY TYPE:
740
ADDRESS:130 ANNA DR.TELEPHONE:
(310) 531-6049
CITY:WINDSORSTATE: CAZIP CODE:
94592
CAPACITY: 4CENSUS: 4DATE:
04/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Alyssa McDonaldTIME COMPLETED:
11:26 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct a Pre-Licensing Inspection and met with Administrator, Alyssa McDonald. Facility has applied for a Change of Ownership but plans to retain Alyssa as the Administrator.

Upon arrival, LPA observed multiple Covid-19 posters and a screening station for visitors. LPA confirmed that all visitors are screened upon entry including having their temperature checked and that staff is conducting vaccination verification. Facility is a one story residence with three client bedrooms (one shared, two private), a staff bedroom, one client bathroom and common areas. All client rooms are furnished per regulation. Bathroom showers have non-skid mat and grab bars. Water temperature read at 107 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked closet in the hallway for medication and first aid kit. Cleaning supplies and toxins are locked in a cabinet in the laundry room. Perishable and non-perishable foods observed per regulation. Facility has areas inside and outside for visiting and activities. Facility maintains an emergency supply of food and water.

Facility received an approved fire clearance dated January, 4 2022 that allows for four ambulatory clients. Current license allows for one non-ambulatory room and a non-ambulatory client currently resides in that room. Carbon Monoxide detector was tested and operational.

LPA gave Administrator information on how to sign up for the Guardian. LPA confirmed that Administrator is signed up to receive the Provider Information Notices (PINs) that the department sends out. Component III is waived.

Facility must submit an updated facility sketch with a non-ambulatory room so a new fire clearance may be requested. Once CCL receives updated sketch and fire clearance is approved, LPA will notify Application Unit so application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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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