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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700748
Report Date:
05/09/2024
Date Signed:
05/09/2024 02:44:37 PM
Document Has Been Signed on
05/09/2024 02:44 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:
6
CENSUS:
3
DATE:
05/09/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Care Staff Princess Major-Banks
TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a proof of correction (POC) visit. LPA Lund met with Care Staff Princess Major-Banks and explained the reason for the visit. Care Staff called Administrator Karen Fomby who could not make today visit. Administrator Karen Fomby gave permission to have Care Staff Princess Major-Banks sign any required paperwork. Census:3
LPA Lund received proper POC documentation for the deficiency cited on 2/2/2024.
No deficiencies were observed and cited during this visit.
Exit interview conducted 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:
05/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2024
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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