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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700748
Report Date: 11/10/2020
Date Signed: 11/10/2020 04:24:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SISTERS ASSISTED LIVINGFACILITY NUMBER:
502700748
ADMINISTRATOR:FOMBY, KARENFACILITY TYPE:
740
ADDRESS:1006 DURANT STREETTELEPHONE:
(510) 990-1683
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:4CENSUS: 0DATE:
11/10/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Karen Fomby, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) T. White contacted the Applicant via telephone to commence an announced Pre-Licensing Tele-Inspection visit on 11/10/2020 at 1:00pm due to COVID-19 and pre-cautionary measures. LPA was allowed entry into the home via Facetime.

LPA toured the residents bedrooms, bathrooms, dining rooms, common living areas, kitchen, and backyard. There is sufficient lighting around the facility. Residents rooms are equipped with the proper lighting. Residents rooms have proper bedding and linens for the residents to use. The kitchen was observed cleaned and within compliance. Living room is equipped with the proper furniture for the clients. All toxins and sharp objects are locked. Passageways and hallways are free of obstruction. Fire extinguisher is in compliance. Smoke detectors and Carbon Monoxide detector are equipped around the facility. Medication cabinet has a lock and first aid kit is complete. Hot water temperature is measured at 110 degrees Fahrenheit. LPA observed a supply of 2-day perishable and 7-day nonperishable foods available for the clients.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. An exit interview was conducted with Applicant via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

LPA T. White conducted Component III presentation via Facetime on 11/10/2020 starting at 2:40pm.
LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted with Licensee and a copy of this report provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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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