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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 04/18/2023
Date Signed: 04/18/2023 12:57:49 PM

Document Has Been Signed on 04/18/2023 12:57 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 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:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Direct Support Professional, Nathaniel NeishTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Direct Support Professional, Nathaniel Neish. Acting Administrator, Jasmine Sampson and Licensee, Jenero Jefferson were available by phone.

Upon arrival, LPA observed that staff was wearing a mask and screened LPA. LPA communicated to staff that masking and screening was no longer required per current guidance and asked if facility was choosing to continue those practices as a policy. Staff was unsure. LPA has previously sent communication to Licensee requesting an updated Infection Control Plan which should include facility policy on masking and screening. LPA initiated a tour of the facility around 8:40am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident bathroom measured at 108 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked.

Fire extinguisher was last inspected March 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted March, 2023.

Four staff files and four resident files were reviewed. Three of four staff do not have required First Aid and CPR certificates. Four out of four staff do not have required documented training. Three of four staff plus the identified Administrator are not associated to the facility.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 7
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 ANNA HOME
FACILITY NUMBER: 496804043
VISIT DATE: 04/18/2023
NARRATIVE
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Continued from LIC809

LPA confirmed that staff have valid fingerprint clearances but were not associated to this facility. Licensee associated identified staff to facility during this inspection. Three of four residents do not have updated Admission Agreements that reflect the new facility.



Administrator Certificate for Licensee/Administrator Jefferson Jenero A 6060264735 expires 8/3/2023. Facility has not submitted paperwork to change the Administrator to Jasmine Sampson despite the posted LIC500 Personnel Report dated January 2023 that identifies Jasmine as the designated Administrator and Licensee identifying Jasmine as the Administrator when associating them to the facility. Medications and medication records were reviewed. Client P&I documentation has not been updated and cash was not available for review.

Licensee/Administrator to submit updates of the following documents by 5/18/2023:
Liability Insurance
Surety Bond
LIC308 Designation of Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)
Documents required for Change of Administrator

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: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 04/18/2023 12:57 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 04/18/2023 at 12:10 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 ANNA HOME
FACILITY NUMBER: 496804043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above in four out of five staff not being associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2023
Plan of Correction
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Licensee assocaited identified staff during this inspection. Deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/18/2023 12:57 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 04/18/2023 at 12:10 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 ANNA HOME
FACILITY NUMBER: 496804043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(D)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four staff's documented training does not indicate the hours for each training topic which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Facility agrees to updated the form used to document training to include training hours and all other requirements set by regulation 87412. Updated form to be sent to CCL not later than POC due date, 4/21/2023.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/18/2023 12:57 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 04/18/2023 at 12:10 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 ANNA HOME
FACILITY NUMBER: 496804043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four staff not having required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Facility agrees to submit a training schedule for all staff to be trained in the next 30 days. Training schedule due no later than POC due date, 4/21/2023.

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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/18/2023 12:57 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 04/18/2023 at 12:10 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 ANNA HOME
FACILITY NUMBER: 496804043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of four staff not having valid First Aid Certificates which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Facility agrees to submit proof that all staff have a valid First Aid Certificate no later than POC due date, 4/21/2023.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four staff not having required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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4
Facility agrees to submit a training schedule for all staff to be trained in the next 30 days. Training schedule due no later than POC due date, 4/21/2023.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/18/2023 12:57 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 04/18/2023 at 12:10 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 ANNA HOME
FACILITY NUMBER: 496804043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two residents not having a Medical Assessment in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2023
Plan of Correction
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Facilty agrees to review all resident files and ensure that all Medical Assessmenst are up tp date based on resident's current needs. Self Certification indicating that files are complete to be submitted to CCL bo later than POC due date, 5/2/2023.
Type B
Section Cited
CCR
87507(a)
Medical Assessment
87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on record review, the licensee did not comply with the section cited above in three out of four residents not having an updated Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2023
Plan of Correction
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3
4
Facilty agrees to review all resident files and ensure that all Admission Agreements are updated to reflect the new facility. Self-Certification indicating that files are complete to be submitted to CCL bo later than POC due date, 5/2/2023.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
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