500305863-3-26-2021-27-AS-CACL-BZLTP5-20210330145347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 500305863
Report Date: 03/26/2021
Date Signed: 03/26/2021 04:31:04 PM

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
09/14/2020 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200914170134

FACILITY NAME:	GEORGIA'S GUEST HOME		FACILITY NUMBER:	500305863
ADMINISTRATOR:	GEORGIA WILCOMB		FACILITY TYPE:	740
ADDRESS:	102 SOUTH G STREET		TELEPHONE:	(209) 521-5350
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY:	15	CENSUS:	DATE:	03/26/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator, Georgia Wilcomb		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Personal Rights: Caregiver is not accepting resident back into care.

INVESTIGATION FINDINGS:

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On 3/26/21 at 2:30pm Licensing Program Analyst (LPA) Kevin Gould made an unannounced tele-inspection to the Georgia's Guest Home RCFE to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated by statements made by S1, RP and R1. S1 and RP both corroborated that a facility representative did not conduct a physical assessment of R1 to ensure R1 had returned to baseline and the facility could meet the needs of the resident. S1 states she received conflicting reports of R1's ability from hospital coordinators and nursing staff of R1's baseline evaluation but never went to the hospital to evaluate R1 for a higher level of care. R1 corroborated the allegations and stated no facility staff ever came to the hospital to conduct an evaluation so R1 could be returned to the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20200914170134

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: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
	VISIT DATE: 03/26/2021

NARRATIVE

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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal rights is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator and a copy of this report and appeal rights will be mailed to the facility for signature.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20200914170134

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: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/09/2021 Section Cited CCR 87468.2(a)(20)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations andshall comply with all	1 2 3 4 5 6 7	Licensee will submit a written plan of correction to ensure any resident who's needs cannot be met will be assessed by the facility and will outline the procudres the facility will follow if they are unable to meet the needs of the resident and need to transfer the resident to a higher level of care.
	8 9 10 11 12 13 14	eviction and relocation protections for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. THis requiremnt was not met as evidenced by: R1 was not accempted back to the facility in a timely manner.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021

LIC9099 (FAS) - (06/04)

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