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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700748
Report Date: 10/26/2021
Date Signed: 10/26/2021 02:10:14 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: 2DATE:
10/26/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Karen FombyTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address unannounced to do a Post Licensing & Annual required inspection. LPA explained the reason for the visit to Administrator Karen Fomby.

LPA Lund & Administrator Karen Fomby toured the facility which include the resident’s 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. Smoke detectors and Carbon Monoxide detector are equipped around the facility. Medication cabinet has a lock and first aid kit is complete. 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 Administrator Karen Fomby and a copy of this report was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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