496804043-11-8-2024-21-AS-CARD-DATS8U-20241108123944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:39:52 PM

Document Has Been Signed on 11/08/2024 12:39 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	FOREVER SARAHS ANNA HOME		FACILITY NUMBER:	496804043
ADMINISTRATOR/ DIRECTOR:	MCDANIEL, JUANITA		FACILITY TYPE:	740
ADDRESS:	130 ANNA DR.		TELEPHONE:	(707) 838-7237
CITY:	WINDSOR	STATE: CA	ZIP CODE:	94592
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	11/08/2024
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Jenero Jefferson		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE

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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, Licensing Program Analyst Chris Arnhold and representatives from North Bay Regional Center met with Licensee, Jenero Jefferson to conduct a Non-Compliance Conference.

Parties discussed multiple areas of concern including but not limited to the following:
· Licensee did not comply with a recent audit conducted by the Department
· Licensee did not notify licensing that all properties are in foreclosure.
· Licensee is having financial issues that have resulted in the regional center paying taxes that are the responsibility of the Licensee and staff have received delays in receiving their paychecks.
Licensee to ensure the following:
· Licensee to ensure all documents that were requested by the CCL auditor to be sent to CCL no later than Tuesday, November 12, 2024
· Licensee to provide a written statement outlining the current status of the foreclosure and what their plan is in the event that the facility is not able to maintain control of property no later than Tuesday, November 12, 2024.
· Licensee to review H&S code 1562.2 for ARF homes and 1569.686 for RCFE home and follow through with reporting requirements listed. Licensee to submit copies of required notifications and self-certification of compliance no later than Tuesday, November 12, 2024.
Licensee agrees to be placed on a non-compliance plan for a period of two years.

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 Licensee. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

The Departments Technical support will continue to provide support during the agreed upon timeline.

Bethany Moellers	TELEPHONE: (707) 588-5040
Christopher Arnhold	TELEPHONE: (707) 588-5084
	DATE: 11/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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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Document Has Been Signed on 11/08/2024 12:39 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

1569.686(a)(1)(c) Licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within 2 business days…of any of the following events, or knowledge of the event: (1) A notice of default, notice of trustee's sale, or any other
	Deficient Practice Statement
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	POC Due Date: 11/12/2024
	Plan of Correction
1 2 3 4	Licensee to provide a written statement outlining the current status of the foreclosure and what their plan is in the event that the facility is not able to maintain control of property no later than POC due date 11/12/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Bethany Moellers	TELEPHONE: (707) 588-5040
Christopher Arnhold	TELEPHONE: (707) 588-5084
	DATE: 11/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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