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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 07/07/2022
Date Signed: 07/13/2022 08:54:57 AM

Document Has Been Signed on 07/13/2022 08:54 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 ANNA HOMEFACILITY NUMBER:
496804043
ADMINISTRATOR:JEFFERSON, JENEROFACILITY TYPE:
740
ADDRESS:130 ANNA DR.TELEPHONE:
(310) 531-6049
CITY:WINDSORSTATE: CAZIP CODE:
94592
CAPACITY: 4CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Direct Support Staff, Nathaniel NeishTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct a Post Licensing inspection
and met with Direct Support Staff, Nathaniel Neish. Administrator, Jenero Jefferson was unavailable during
inspection but was available by phone. The inspection is focused on the Infection Control procedures and
practices of this facility.

Upon arrival, LPA was asked to sign in and was screened for temperature. LPA conducted a walk-through of
the facility and observed Covid-19 posters throughout that included hand washing signs. Facility was a
comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout the
facility. Observed staff had N95 masks on during this visit. LPA informed staff that they may wear surgical
masks instead of N95 masks if there is no active Covid in the facility. Staff are screened before each shift for
Covid-19 symptoms and clients are screened twice per day. Temperatures are documented.
LPA and staff discussed client activities and visitation. Facility has a designated visitation area indoors and
outdoors. Facility does not have frequent visitors but does currently allow inside and outside visitation. LPA
instructed staff to review Provider Information Notice (PIN) 21-40-ASC regarding vaccination verification.
Commonly touched surfaces are disinfected twice per day, on the AM shift and the PM shift.. LPA has
requested Administrator to review all staff files to ensure that staff are adequately trained regarding infection
control and proper donning and doffing of PPE. Some staff have been N95 fit tested.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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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 ANNA HOME
FACILITY NUMBER: 496804043
VISIT DATE: 07/07/2022
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Continued from LIC809

Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to
masks, face shields, gowns and hand sanitizer. PPE is located in an area that is accessible to staff who need
it. Facility maintains a 30 day supply of medication.
Fire extinguisher was last serviced November 2021. Smoke detectors throughout the facility and Carbon
Monoxide detector was tested and operational.
Staff and LPA discussed their Emergency Disaster Plan. LPA discussed the Infection Control Plan with the
Administrator
No deficiencies cited during this inspection.
SUPERVISOR'S
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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