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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700748
Report Date:
11/16/2023
Date Signed:
11/16/2023 02:39:21 PM
Document Has Been Signed on
11/16/2023 02:39 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
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
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:
11/16/2023
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Administrator Karen Fomby
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a proof of correction visit. LPA Lund met with Administrator Karen Fomby and explained the reason for the visit.
LPA Jason Lund received documentation (Proof of correction) for the two deficiencies from the visit on 11/3/2023.
An exit interview was conducted with Administrator Karen Fomby and report left.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Jason Lund
TELEPHONE:
(916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE:
11/16/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
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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