502700748-8-21-2023-27-AS-SRIN-CV643M-20230828184454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700748
Report Date: 08/21/2023
Date Signed: 08/21/2023 04:25:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2023 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20230419111449

FACILITY NAME:	SISTERS ASSISTED LIVING		FACILITY NUMBER:	502700748
ADMINISTRATOR:	FOMBY, KAREN		FACILITY TYPE:	740
ADDRESS:	1006 DURANT STREET		TELEPHONE:	(510) 990-1683
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	4	CENSUS: 6	DATE:	08/21/2023
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Administrator Karen Fomby		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff did not have resident's authorized representative sign an admission's agreement for care

Staff refused to provide resident's authorized representative wth information about resident's care

Staff are overcharging resident for care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation. LPA Lund met with Administrator Karen Fomby and explained the reason for the visit.

Staff did not have resident's authorized representative sign an admission's agreement for care- 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. The hospital paid the admission fee for R1 for the first four months. R1’s husband has a Durable Power of Attorney for finances dated June 4, 2021, but does not have authorization to make medical and other health-care decisions. R1 husband refused to pick up R1 from hospital and case worker (Hospital) had R1 admitted to the facility on 9/20/2022.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230419111449

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 502700748
	VISIT DATE: 08/21/2023

NARRATIVE

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Based on records review, interviews with, Administrator Karen Fomby, RP and witness the information provided, it was unclear if staff did not have resident's authorized representative sign an admission's agreement for care therefore the allegation was deemed UNSUBSTANTIATED.

Staff refused to provide resident's authorized representative with information about resident's care- Based on records reviewed and interviews conducted with Administrator Karen Fomby, Reporting Party (RP) and witness. Resident (R1) was admitted to the facility on 9/20/2022 from Dignity Health Mercy Medical Center in Merced California. R1 husband refused to pick up R1 from hospital and case worker (Hospital) had R1 admitted to the facility. R1’s husband has a Durable Power of Attorney for finances dated June 4, 2021, but does not have authorization to make medical and other health-care decisions. R1’s LIC602 dated 8/11/2022 stated that R1 needs help with bathing, grooming, and medication management.

Based on records review, interviews with, Administrator Karen Fomby, RP and witness the information provided, it was unclear if staff refused to provide resident's authorized representative with information about resident's care therefore the allegation was deemed UNSUBSTANTIATED.

Staff are overcharging resident for care- Based on records reviewed and interviews conducted with Administrator Karen Fomby, Reporting Party (RP) and witness. Resident (R1) was admitted to the facility on 9/20/2022 from Dignity Health Mercy Medical Center in Merced California. Dignity Health Mercy Medical Center signed the admission agreement on 9/20/2022 and R1’s husband has no responsibility for payments due to not signing the admission agreement dated 9/20/2022. R1’s husband does have a Power of Attorney for finances dated June 4, 2021, but does not have authorization to make medical and other health-care decisions.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230419111449

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 502700748
	VISIT DATE: 08/21/2023

NARRATIVE

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Based on records review, interviews with Administrator Karen Fomby, RP and witness the information provided, it was unclear if staff are overcharging resident for care therefore the allegation was deemed UNSUBSTANTIATED.

The Department (CCLD) has found the allegations. Unsubstantiated.

A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted with Administrator Karen Fomby and report left.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC9099 (FAS) - (06/04)

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