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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700748
Report Date: 02/22/2024
Date Signed: 02/22/2024 11:39:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2024 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20240102142039
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:6CENSUS: 5DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Karen FombyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff abandoned a resident at the hospital
INVESTIGATION FINDINGS:
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On 2/22/2024 Licensing Program Analyst (LPA) Jason Lund arrived unannounced to amend a complaint investigation. LPA Lund met with Administrator Karen Fomby and explained the reason for the visit. LPA Lund had to do a new LIC9099 based not having a LIC9099 D on the previous complaint.

Facility staff abandoned a resident at the hospital- Based on records reviewed and interviews conducted with Administrator Karen Fomby, Reporting Party (RP) and witness. Resident (R1) was admitted as a patient at Dignity Health Mercy Medical Center in Merced California. R1 was admitted at the hospital with no responsible party. On September 20, 2022, the hospital paid the admission fee for R1 to stay at the facility. The facility got paid for the three months of service for R1. From January 1, 2023, through December 31, 2023 the facility didn't get paid for services rendered.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240102142039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SISTERS ASSISTED LIVING
FACILITY NUMBER: 502700748
VISIT DATE: 02/22/2024
NARRATIVE
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On September 20, 2023, the facility filled an Unlawful detainer (UD-23-001136) on September 26, 2023, R1 and Mercy Medical Center was served. On October 6, 2023, the Superior of Court of California County of Stanislaus signed a right to possession. On 12/31/2023 R1 was dropped off at the Emergency Room Dignity Health Mercy Medical Center in Merced California. On 12/31/2023 The licensee left a note with R1 when dropped off which stated R1 has not been paid in 9 months.

Based on records review, interviews with, Administrator Karen Fomby, RP and witness the information provided, it was clear that the facility staff abandoned a resident at the hospital therefore the allegation was deemed SUBSTANTIATED.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240102142039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SISTERS ASSISTED LIVING
FACILITY NUMBER: 502700748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/07/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 (a)(1) to be accorded dignity in their person relationships with staff, residents, and other persons.
This requirement was not met by:
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Administrator will look over the regulation and email LPA Lund confirming they understand the regulation.
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Based on interviews, the licensee left a note with R1 when dropped off which stated R1 has not been paid in 9 months. This poses a potential Health, Safety or Personal Rights risk to residents 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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3