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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:03:48 PM

Document Has Been Signed on 08/14/2024 03:03 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: 0DATE:
08/14/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:43 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:15 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 Victoria Bertozzi, Licensing Program Analyst Christi Coppo, Licensing Program Manager Bethany Moellers, Representatives from North Bay Regional Center, Katy Vanzant and Courtney Singleton and Licensee Jenero Jefferson.

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 to ensure daily operation.
  • Licensee and Administrator effectively communicating with LPA(s), including clearing Plan of corrections timely.
  • How emergencies are 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.
  • Physician Reports and Care Plans not conducted annually when required.

Licensee to submit the following no later than Monday August 19, 2024:
  • LIC500 for each of their facilities showing adequate Administrator oversight of facilities
  • Outstanding POCs
  • Requested pay stubs
  • Documentation to change Administrators

Licensee has accepted referral to the Department's Technical Support Program. LPM will submit referral.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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