502700748-5-9-2024-27-AS-LRIS-D55T6K-20240510142716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700748
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:44:00 PM

Unsubstantiated

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
01/24/2024 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20240124192506

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
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Care Staff Princess Major-Banks		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff did not allow a resident a choice of hospice services

Facility staff signed a hospice transfer request form without the resident's family authorization

Facility staff caused delays in residents at the facility receiving timely hospice services

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation. 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

Facility staff did not allow a resident a choice of hospice services- Based on records reviewed and interviews conducted with Administrator Karen Fomby, Reporting Party (RP) and witnesses. Resident (R1) was admitted to Home Health with Progressive Home Health & Hospice on 5/9/2023 through 1/19/2024. Conservator of R1 made the choice to change hospice services on 1/19/2024 from Bristol Hospice Services to Progressive Home Health & Hospice because the familiarity of staff working with R1.

Unsubstantiated

Estimated Days of Completion: 90

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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240124192506

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: 05/09/2024

NARRATIVE

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Based on records review, interviews with, Administrator Karen Fomby, RP and witnesses the information provided, it was unclear if facility staff did not allow a resident a choice of hospice services therefore the allegation was deemed UNSUBSTANTIATED.

Facility staff signed a hospice transfer request form without the resident's family authorization- Based on records reviewed and interviews conducted with Administrator Karen Fomby, Reporting Party (RP) and witnesses. Resident (R1) was admitted to hospice on 1/17/2024 while at the hospital and was discharged to the facility on 1/18/2024. Conservator for Resident (R1) gave permission to Administrator Karen Fomby to sign the transfer request of Hospice services for R1.

Based on records review, interviews with, Administrator Karen Fomby, RP and witness the information provided, it was unclear if facility staff signed a hospice transfer request form without the resident's family authorization therefore the allegation was deemed UNSUBSTANTIATED.

Facility staff caused delays in residents at the facility receiving timely hospice services- Based on records reviewed and interviews conducted with Administrator Karen Fomby, Reporting Party (RP) and witness. Resident (R1) was admitted to hospice on 1/17/2024 and discharged to the facility on 1/18/2024. The transfer on hospice services from Bristol Hospice Services to Progressive Home Health & Hospice was on 1/19/2024. Records indicate that Progressive Home Health & Hospice Services started services with R1 on 1/19/2024 one day after returning from the hospital on hospice.

Based on records review, interviews with, Administrator Karen Fomby, RP and witness the information provided, it was unclear if facility staff caused delays in residents at the facility receiving timely hospice services 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, 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

LIC9099 (FAS) - (06/04)

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