Forever Sarahs Anna Home

Type of visit: Case Management - Other

At approximately, 9:05 AM Licensing Program Analysts (LPAs) Caitlynn Felias and Robert Frank arrived at Forever Sarahs Anna Home for the purpose of a closure inspection to confirm that there are no residents present at the facility pursuant to a revocation of the facility’s license effective 7/17/2025. Confirmation was made with the North Bay Regional Center that all residents were moved to other facilities prior to 7/17/2025. LPAs inspected the exterior of the building today and observed the interior through windows and found no evidence that would suggest that any residents are residing on the premises. The closure of this facility has been finalized. Facility is closed effective 07/17/2025. LPAs were unable to conduct an Exit interview or obtain a staff signature as there were no staff at the facility.the state’s words, verbatim · CDSS document, Jul 18, 2025

Type of visit: Case Management - Legal/Non-compliance

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... ...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) ...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.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87202(a) · Plan of correction due date: Jun 12, 2025

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: 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...the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625(b)(1) · Plan of correction due date: Jun 12, 2025

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: 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(a)(13)(B) · Plan of correction due date: May 23, 2025

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: 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.618(c)(3) · Plan of correction due date: Jun 12, 2025

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: 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jun 12, 2025

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: 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jun 12, 2025

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: 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87156(a) · Plan of correction due date: Jun 12, 2025

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: 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee to submit the facility's annual licensing fee to Community Care Licensing immediately or by POC Due date of 6/12/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.605 · Plan of correction due date: Jun 12, 2025

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, 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee to submit proof of Liability Insurance coverage to Community Care Licensing by the POC due date of 6/12/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(a) · Plan of correction due date: Jun 12, 2025

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: 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.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee to submit a completed LIC 308 Designation of Responsibility Form to Community Care Licensing by POC due date of 6/12/2025.

Type of visit: Required - 1 Year

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Caregiver (CG) Nathaniel Neish. Caregiver Rosllin Sadullah arrived at 2:00 PM. The Facility currently has no Administrator. This deficiency will be cited. 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. Upon arrival, LPA was informed that there were three (3) residents in care. Two (2) residents were away at day programs during the inspection. At approximately 9:15 AM, LPA reviewed the Facility's Staff Roster and found that two (2) staff members (S2 & S3) were not background cleared on Guardian. This deficiency will be cited. A civil penalty is being issue for this deficiency. All remaining staff were background cleared and associated to the facility per regulation. At approximately 9:25 AM, LPA toured the facility with CG Neish . All exits were clear and unobstructed. 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 was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is not conducting quarterly fire and emergency drills per regulation. This deficiency will be cited. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Continued on 809-C... ...Continued from 809 Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. At approximately 10:25 AM, LPA reviewed three (3) resident files. Two (2) of the resident files did not have current Appraisal/Needs and Services plans. This deficiency will be cited. A Civil Penalty will be issued for this deficiency as it is the second time it has occurred in less than one (1) year. LPA reviewed three (3) staff files. One (1) Staff member (S3) did not have a personnel file at the facility. Two staff members (S1 & S2) did not have proof of current training. These deficiencies will be cited. LPA spot checked Medication for three (3) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not keep resident’s cash for personal and incidental (P&I) items but instead uses residents' debit cards for P&I transactions. Residents have separate accounts and all transactions are being properly logged. LPA requested the following documents be submitted to Community Care Licensing by 5/2/2025: LIC 500 Personnel Report LIC 308 Designation of Responsibility LIC 610E Emergency Disaster Plan Proof of Liability Insurance 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, 811 Confidential Names, LIC 421FCs and Appeal Rights discussed and provided to CG Sadullah. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Office

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.the state’s words, verbatim · CDSS document, Nov 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.686(a)(1)(c) · Plan of correction due date: Nov 12, 2024

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 indication of foreclosure is issued on the property. (c) A licensee who fails to comply with this section may be liable for civil penalties in an amount not to exceed one hundred dollars ($100) for each day of the failure to provide notification required in this section. The total civil penalty shall not exceed two thousand dollars ($2,000). This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not ensuring that CCL was notified when homes went into foreclosure which poses a potential health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Nov 8, 2024

Plan of correction: 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.

Type of visit: Office

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.the state’s words, verbatim · CDSS document, Aug 14, 2024

Type of visit: Required - 1 Year

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... 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 giventhe state’s words, verbatim · CDSS document, May 14, 2024

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.