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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804043
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:22:12 PM

Document Has Been Signed on 05/22/2025 03:22 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:		MCDANIEL, JUANITAFACILITY TYPE:
740
ADDRESS:130 ANNA DRIVETELEPHONE:
(707) 838-7237
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: 3DATE:
05/22/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Nathaniel Neish, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management - Legal/Non-compliance visit and was greeted by Caregiver Nathaniel Neish. Caregiver Roslin Sadullah arrived at 2:00 PM. Forever Sarahs Anna Home is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for four (4) residents. One (1) resident can be non-ambulatory. Three (3) residents must be ambulatory. Upon arrival, LPA was informed that there were three (3) residents in care and one (1) staff members on-site. At approximately 9:10 AM, LPA reviewed the Facility's Staff Roster and found that one (1) staff members (S2) was not background cleared on Guardian. This deficiency will be cited. A civil penalty is being issue for this deficiency.

On 11/8/2024, licensee Jenero Jefferson visited the Santa Rosa Regional Office and agreed to be placed on a non-compliance plan for a period of two years. 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 was to ensure the following:
· Licensee to ensure all documents that were requested by the Community Care Licensing (CCL) auditor to be sent to CCL no later than Tuesday, November 12, 2024.

Continued on 809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
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: 05/22/2025
NARRATIVE
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...Continued from 809

-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.

As of today 5/22/2025, licensee did not fulfill or provide any of the aforementioned items to Community Care Licensing.

At approximately 9:40 AM LPA began a records review as deficiencies from the Annual Inspection conducted on 4/2/2025 have not been cleared. LPA reviewed two (2) resident files. Two (2) of two (2) resident files (R1 & R2) did not have current Appraisal/Needs and Services plans. This deficiency will be cited. LPA reviewed four (4) staff files. Two (2) staff members (S1 & S2) did not have proof of current training. Four (4) staff members (S1, S2, S3 & S4) did not have proof of current First Aid & CPR certification on file. These deficiencies will be cited.

At approximately 10:30 AM, LPA observed that two (2) fire extinguishers were last serviced and tagged in 3/2024. One (1) of three (3) fire extinguishers was last serviced and tagged in 9/2013. This deficiency will be cited.

The facility's annual License Fee was due on 5/4/2025. As of 5/21/2025, the License Fee has not been received by CCL. This deficiency will be cited.

LPA observed that the facility does not have proof of current Liability Insurance coverage on site, nor has the Licensee submitted proof of current Liability Insurance Coverage to CCL. This deficiency will be cited.

Continued on 809-C(2)
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/22/2025 03:22 PM - It Cannot Be Edited


Created By: Robert Frank On 05/22/2025 at 10:45 AM
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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2025
Section Cited
CCR
87202(a)

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87202 Fire Clearance(a) All facilities shall maintain a fire clearance approved by the city,... protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons,...

This requirement is not met as evidenced by:
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Licensee will provide photographic proof that all three (3) fire extinguishers were serviced to Community Care Licensing by POC due date of 6/12/2025.
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Based on observation, the licensee did not comply with the section cited above in that one (1) of three (3) fire extinguishers was last serviced/tagged in 9/2013. Two (2) extinguishers were serviced/ tagged in 3/2024, which poses an immediate health, safety or personal rights risk to...
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Type B
06/12/2025
Section Cited
HSC1569.625(b)(1)

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1569.625 Other Provisions: (1) The department shall adopt regulations to require staff members... residents with...daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff...This requirement is not met as evidenced by:
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Licensee will provide proof to Community Care Licensing that staff members S1 & S2 have completed their annual training per regulation and that this proof of training will be included in their personnel file by POC due date of 6/12/2025.
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Based on observation and record review, the licensee did not comply with the section cited above in that two (2) staff members (S1 & S2) did not have proof of current training which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/22/2025 03:22 PM - It Cannot Be Edited


Created By: Robert Frank On 05/22/2025 at 11:12 AM
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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2025
Section Cited
CCR
87412(a)(13)(B)

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87412 Personnel Records: (a) The licensee...personnel records are maintained on the licensee,... shall contain the...(13) For employees that are required to be fingerprinted...Clearance: (B)...of either a criminal record...by Section 87355(e).
This requirement is not met as evidenced by:
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Licensee will provide proof to Community Care Licensing that staff members S2 have been background cleared and associated to the facility in Guardian by POC due date of 5/23/2025. The staff member cannot work at the facility until they have been background cleared.
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Based on observation and record review, the licensee did not comply with the section cited above in that one (1) staff members (S2) were not background cleared on Guardian which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
06/12/2025
Section Cited
HSC1569.618(c)(3)

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1569.618 Administration and management of residential care facilities; ...employee scheduling: (c) The...(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is...at all times.... provide CPR. This requirement is not met as evidenced by:
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Licensee will provide proof to Community Care Licensing that staff members S1, S2, S3 & S4 have their CPR and First Aid certification by POC due date of 6/12/2025.
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Based on observation and record review, the licensee did not comply with the section cited above in that four (4) staff members (S1, S2, S3 & S4) did not have proof of CPR and First Aid training in their staff files which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/22/2025 03:22 PM - It Cannot Be Edited


Created By: Robert Frank On 05/22/2025 at 12:09 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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2025
Section Cited
CCR
87463(a)

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Reappraisals(a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be... writing as frequently as necessary or once every 12 months, whichever...the updated...shall be referred to as the reappraisal. This requirement is not met as evidenced by:
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Licensee to submit completed current Appraisal, Needs, and Services Plans for R1 and R2 to Community Care Licensing by POC Due Date of 6/12/2025
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Based on observation and record review, the licensee did not comply with the section cited above in R1 and R2 did not have current Appraisal, Needs, and Services Plan, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
06/12/2025
Section Cited
CCR87405(a)

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87405Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator. The licensee and the...fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
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Licensee will employ an Administrator with a valid Administrators certificate on file with Community Care Licensing. Licensee will submit all documentation to Community Care Licensing to make this employee the new Administrator by the POC Due Date of 6/12/2025.
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Based on record review, the licensee did not comply with the section cited above in that the facility has no employed Administrator which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/22/2025 03:22 PM - It Cannot Be Edited


Created By: Robert Frank On 05/22/2025 at 12:48 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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2025
Section Cited
CCR
87156(a)

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Licensing Fees (a)An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.

This requirement is not met as evidenced by:
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Licensee to submit the facility's annual licensing fee to Community Care Licensing immediately or by POC Due date of 6/12/2025.
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Based on observation and record review, the licensee did not comply with the section cited above in that as of 5/21/2025, the License Fee has not been received by Community Care Licensing which poses a potential health, safety or personal rights risk to persons in care.
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Type B
06/12/2025
Section Cited
HSC1569.605

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Liability insurance; coverage requirements On and after... all residential care facilities for the elderly...shall maintain liability insurance... ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total...
This requirement is not met as evidenced by: Based on observation and record review,
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Licensee to submit proof of Liability Insurance coverage to Community Care Licensing by the POC due date of 6/12/2025.
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the licensee did not comply with the section cited above in that the facility does not have proof of Liability Insurance coverage on site, nor has the Licensee submitted proof of current Liability Insurance which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
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: 05/22/2025
NARRATIVE
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...Continued from 809-C

Currently the facility does not have an administrator. This deficiency will be cited.

A facility manager designated by the licensee with notice to the department (CCL), shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. Through record review LPA observed that the Licensee has not provided a LIC 308 Designation of Responsibility Form to CCL. This deficiency will be cited.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 421BG Civil Penalty, 811 Confidential Names and Appeal Rights discussed and provided to Caregiver Sadullah. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
Page: 9 of 9
Document Has Been Signed on 05/22/2025 03:22 PM - It Cannot Be Edited


Created By: Robert Frank On 05/22/2025 at 02:13 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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2025
Section Cited
HSC
1569.618(a)

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Administration and management of residential care facilities;... A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the...temporarily absent from the facility. This requirement is not met as evidenced by:
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Licensee to submit a completed LIC 308 Designation of Responsibility Form to Community Care Licensing by POC due date of 6/12/2025.
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Based on record review, the licensee did not comply with the section cited above in that a LIC 308 Designation of Responsibility Form has not been provided to CCL which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
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