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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:58:29 PM

Document Has Been Signed on 05/14/2024 04:58 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/
DIRECTOR:		SAMPSON, JASMINEFACILITY TYPE:
740
ADDRESS:130 ANNA DR.TELEPHONE:
(310) 531-6049
CITY:WINDSORSTATE: CAZIP CODE:
94592
CAPACITY: 4CENSUS: 4DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:13 PM
NARRATIVE
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Administrator and residents not at facility when LPAs arrived. LPA called Admin who said they were at Walmart and would be here in 10 minutes. Admin showed up at 1:15pm

Licensing Program Analyst (LPAs) Christi Coppo and Jacqueline Macias arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Jasmine Sampson. Facility contact information was reviewed.

At approximately 1:30pm LPAs toured the building and grounds. Tank in backyard filled with green and blue fuzzy substance. Portable commode filled with urine of thick consistency. Broken shutters in bathroom and living room. Window in bathroom has black and brown spotting around sill. Plastic mat under the kitchen sink partially covered with green and blue film and black substance. Soiled brief left in uncovered trash bin (deficiency cited, see 809D).

The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Head of cauliflower had black spots on top and at the base with watery consistency in bag (deficiency cited, see 809D).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. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 106 degrees F which is within the allowable range of 105 to 120 degrees F. 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 were conducted 2/21/2024.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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: 05/14/2024
NARRATIVE
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 Continued from 809...

At approximately 2:30pm LPAs conducted a review of five staff records. S1 and S5 did not have a health screen or TB clearance (deficiency cited, see 809D). At approximately 3:30pm LPA conducted a review of resident files. R1, R2, and R3 did not have Physician's report LIC602 (deficiency cited, see 809D). R1, R2, R3, and R4 did not have current Appraisal, Needs, and Services Plan (deficiency cited, see 809D).

At approximately 3:30pm LPAs and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet.

Jasmine Sampson Administrator Certificate 6047455740 expires 10/18/2024. Fees due. LPA gave Admin LIS print out with PIN. LPA reviewed cash/P&I. No deficiencies.



LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

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
Liability Insurance
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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given

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

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 05/14/2024 04:58 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2024 at 04:36 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: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that S1 and S5 did not have a health screen or TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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2
3
4
Facility to submit pictures of completed Health Screens with TB clearance by plan of correction of 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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/14/2024 04:58 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2024 at 04:36 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: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that there was a tank in backyard filled with green and blue fuzzy substance. Portable commode filled with urine of thick consistency. Broken shutters in bathroom and living room. Window in bathroom has black and brown spotting around sill. Plastic mat under the kitchen sink filled with green and blue film and black substance. Soiled brief left in uncovered trash bin which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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Facility to submit pictures of cleaned/repaired items: window shutters and window sill. Soiled brief, plastic mat, portable commode thrown away immediately while LPA was at facility. Pictures due to CCL by plan of correction due date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that head of Cauliflower has black spots on top and at the base with watery consistency in bag. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Facility immediately discarded cauliflower. Deficency 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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/14/2024 04:58 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2024 at 04:36 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: 05/14/2024

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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2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in that R1, R2, and R3 did not have 602, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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3
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Facility to submit pictures of completed LIC602s for R1, R2, and R3 by plan of correction due date.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin record review, the licensee did not comply with the section cited above in R1, R2, R3, and R4 did not have current Appraisal, Needs, and Services Plan, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
1
2
3
4
Facility to submit pictures of completed current Appraisal, Needs, and Services Plans for R1, R2, R3, and R4 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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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