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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:40:48 PM

Document Has Been Signed on 04/26/2023 03:40 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: 0DATE:
04/26/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee Jenero Jefferson and Administrator, Jasmine SampsonTIME COMPLETED:
03:45 PM
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analysts Dina Alviso, Victoria Bertozzi, Farhaan Sarangi, Shannan Hansen and representatives of the facility, Licensee Jenero Jefferson and Administrator, Jasmine Sampson.

The purpose of the informal conference was explained to the Licensee. Items addressed in today's meeting include but are not limited to compliance issues outlined below:
  • Licensee ensuring that Administrator is spending a sufficient number of hours at the facility.
  • Licensee and Administrator effectively communicating with LPA(s).
  • How are emergencies handled when Licensee and Administrator are not able to physically be at the facility timely.
  • Staff are not trained per regulation including expired First aid and CPR Certificates.
  • Staff were not associated to facility
  • Plan of corrections have not been cleared timely.


Licensee currently has two pending applications under review by the Department. During todays meeting the change of ownership process was discussed and applicant was informed responsibility for oversight is not effective until the new license is issued. Licensee is aware that the Regional Office works collaboratively with other agencies such as labor board and agrees to ensure compliance with all laws and regulations.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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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: 04/26/2023
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Continued from LIC809

Items needed:
  • Plan of Corrections cited during Annual Inspection due no later than Monday May 1, 2023.
  • Licensee to submit updated Plan of Operation outlining how emergencies will be handled when Administrator and/or Licensee are not able to come to the facility timely due no later than 5/26/2023.
  • LIC500 for Forever Sarahs Anna Home and Forever Sarahs Elderly Care Corp.

No deficiencies cited during today’s informal conference office visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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