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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700748
Report Date: 07/21/2026
Date Signed: 07/21/2026 01:53:02 PM

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
05/14/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260514144343
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: 3DATE:
07/21/2026
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Karen FombyTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff has not provided refund after resident's death.
INVESTIGATION FINDINGS:
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LPA arrived to the facility on 7/21/26 at 9:09Am to conduct a complaint investigation into the above allegations, LPA met with administrator Karen Fomby to explain the purpose of the visit. As to the allegation that Staff has not provided refund after resident's death, the LPA reviewed the cash resources of the resident. in interview with the administrator it was learned the client had paid basic services from march through to the end may in advance, and had passed on 4/19/26, leaving a month and some days of funds that should be returned.
LPA reviewed a photo of the sent check for 4160 drafted 5/16/26 payable to "the estate of jack manning" and a recipt for certified mail dated 5/21/26 with the client representative's signiture verifying it was recieved. the check has not been cashed as of 7/21/26 and the facility remains in control of the funds. In interview it was learned the check is likely not been cashed due to the payable line not being directed to the clients representative, in this case the clients offspring who has durable power of attourney. the amount may come into dispute, the facility is obligated to return a prorated value, calculated as the basic services divided by the number of days in the month after the clients property has been removed. The original check value is for 10 prorated days days + 1 month on its purpose line.
Continued on C,page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
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 4
Control Number 27-AS-20260514144343
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: 07/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2026
Section Cited
CCR
87217(j)(3)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables (j) Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded. (3) If no executor or administrator has been appointed, the responsible person shall be notified, and the cash resources, personal property, and valuables shall be surrendered to said person in exchange for a signed itemized receipt.
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LPA suggested the POC should include canceling the current check and reissuing the refund to the clients representative and sent certified. Licensee agreed to cancel and reissue, sending the LPA pictures of the rewritten check and the signed back certified mail reciept by the poc date
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This requirement was not followed as evidenced by, record review of the check is issued to the estate without evidance of an executor or administrator of the estate seperate from the DPOA,
Not following this requirement posed a risk to the clients in care, via health, saftey, or personal rights
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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: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20260514144343
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: 07/21/2026
NARRATIVE
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The LPA issued guidance that the facility is required by regulation to collect a signed receipt of the property that was returned to the clients representative.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations,is being cited on the attached LIC 9099D.

A copy of the report was read and given to the administrator, appeal rights were provided. exit interview conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20260514144343
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: 07/21/2026
NARRATIVE
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Supplemental to the second allegation, record review of the MAR indicated that the prescriptions were given as ordered and PRN administration was documented appropriately. It's unclear by the mar documentation, that a particular medication was given too often, or another medication was not given often enough, as the client has multiple regular medications which can cause chemical restraint type effects. Review of the 602 and medical records both indicated a certain level of psychotropic medication was needed to address agitation with physical violence. LPA gave guidance that if the medication is being noticed as too effective at sedating a client, that would bear health and personal rights risks that should be addressed with client and their the primary care provider/psych.

As to the fifth allegation, it was learned in interview with the hospice care nursing administrator that no order for bedrails existed, and no bedrails were supplied to the facility. 602 doesnt indicate the need for bedrails, no doctors order for bedrails is on file at the facility.

as to the sixth allegation, it was learned in interview with the administrator that the clients property was released to the clients representative on 4/21/26, for which a previous arrangement was reached on the 4/19. the recovery of the property did not include a signed receipt, as the representative of the client refused to sign, but they allowed a picture of thiery drivers license be taken. LPA gave guidance that per regulation the licensee must allow reasonable access to the property for the collection of safeguarded valuables. LPA toured the facility and the list of safeguarded valuables is not currently within the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

a copy of the report was read and given to the administrator, no citations issued, exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 1 of 1
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
05/14/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260514144343

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: 3DATE:
07/21/2026
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:karen fombyTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff mismanaged resident's medication, resulting in death
Staff chemically restrained resident
Staff did not ensure resident drank water, resulting in dehydration
Staff did not ensure resident ate food, resulting in malnutrition and weight loss
Staff did not install bed rails as advised by hospice doctor
Staff refused to release deceased resident's belongings to authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Noel Wolf Petersen arrived to the faciltiy to conduct a complaint investigation related to the above allegations. LPA met with Karen Fomby to explain the purpose of the visit.
As to the first, second, third, and fourth allegations, the department learned through record review of the clients hosptial records that on 04/15/2026, the client r1, was seen at Memorial Medical Center for a complaint of increased weakness, thier final diagnosis was failure to thrive in adult, Bradycardia, hypotension, hypothermia, and dementia. R1 was released to hospice on 04/16/2026. It should be noted that during thier hospital visits (3/13, 3/22, 4/8, and 4/15 of 2026) a physical examination was done and r1's weight remained in normal range, there was no mention of malnutrition or dehydration in the medical records. One of 4 medical records from the hospital visits sugested an increase in psychotropic medication was necessisary, none suggested the client was chemically restrained. a in a record review of the death certificate, it was learned on 04/19/2026, R1 passed away, the immediate cause of death was listed as Senile Degeneration of the Brain with the underlying cause listed as Dementia. Other significant conditions that contributed to thier death, but did not result in the underlying cause were Hypertension and Osteoarthritis. No additional conditions that may have contributed to his death were listed on the death certificate.
continued on c page
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4