500305863-7-12-2021-27-AS-RWAE-C4UHVZ-20210712063244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 07/09/2021
Date Signed: 07/12/2021 06:32:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	GEORGIA WILCOMB		FACILITY TYPE:	740
ADDRESS:	102 SOUTH G STREET		TELEPHONE:	(209) 529-7872
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY:	15	CENSUS: 12	DATE:	07/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator - Georgia Wilcomb		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced visit on this day for the purpose of conducting a Required - 1 Year Annual. LPA explained purpose of visit with Caregiver Mark Toole. Administrator (AD) Georgia Wilcomb was notified of the visit by CG and arrived at approximately 9:15 AM to finish visit with LPA. LPA reviewed five resident files. LPA reviewed admission's agreements, medical assessments, TB and appraisals. LPA requested to review 3 staff files. LPA verified criminal record clearances. LPA reviewed training records, All staff have current CPR/First Aid/AED certificates. LPA toured the facility with Administrator. Fire extinguishers were mounted and charged with the last service date of 3/22/2022. LPA reviewed food services. There was enough food on hand to meet the 2 day perishable and 7 day non-perishable requirement. Bathrooms and hand washing areas were observed clean and sanitary. There is a back wall in northwest end bathroom that needs to be replaced behind the toilet. Dry rot and LPA's foot went through the wall down near bottom of the wall near shower. Non-slip mats were observed in shower. Hot water temperature was measured in 2 of 2 resident bathrooms. Water temperature was recorded at 107.3 and 111 degrees F. All toxins were not stored inaccessible to residents in care. The facility was at a comfortable temperature for residents in care. Medications were observed centrally stored and inaccessible. Continued on 809-C Page 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/09/2021

NARRATIVE

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Continued from 809 - Page 2

In order to keep the facility file current please provide the following documentation to CCL by 7/23/2021: LIC 308 - Designation of Administrator, LIC 400 - Affidavit Regarding Cash, LIC 500 - Personnel Summary, LIC 610-E Emergency Disaster Plan, and Current Administrator Certificate.

The following deficiencies were cited on 809-D per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this report along with appeal rights provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/09/2021 Section Cited	1 2 3 4 5 6 7	80087(g)(1) Buildings and Grounds Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	LPA observed an unlocked laundry room with the following chemicals: Bleach, Furniture Polish, and Germicide Cleaner. Licensee did not ensure that chemicals were locked up. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 08/06/2021 Section Cited	1 2 3 4 5 6 7	80088(e)(3) Furniture, Fixtures, Equipment, and Supplies All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	LPA observed the lower wall behind toilet in the northwest end of building. The wall has dry rot near the bottom of the wall near shower. Licensee did not ensure that the bathroom is safe and sanitary for operating condition. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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