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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 05/23/2023
Date Signed: 05/30/2023 05:17:26 PM


Document Has Been Signed on 05/30/2023 05:17 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GEORGIA'S GUEST HOMEFACILITY NUMBER:
500305863
ADMINISTRATOR:GEORGIA WILCOMBFACILITY TYPE:
740
ADDRESS:102 SOUTH G STREETTELEPHONE:
(209) 529-7872
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:15CENSUS: 12DATE:
05/23/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Georgia Wilcomb and Steven Paul HardinTIME COMPLETED:
11:30 AM
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An Informal Conference (IC) was conducted on this day, 05/23/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Informal Conference meeting was to follow up with the facility after a complaint was filed and investigation completed. Present in the meeting was Licensing Program Manager (LPM) LPM Liza King, Licensing Program Analyst (LPA) Charlie Yang, Licensing Program Analyst (LPA) Kimberly Viarella, and Facility Designated Administrator Steven Paul Hardin with Licensee Georgia
Wilcomb.

The Informal Conference process was explained during this meeting to include the Administrative Process as well.

The focus of the concerns at this time were as followed:
  • Designated Facility Administrator-Qualifications/Duties
  • Facility staffing
  • Physical Plant Issues-Flooring/Carpeting for facility bedrooms and common areas
  • Maintaining continued compliance
  • Oversight of facility staff for proper care and supervision
  • Reporting Requirements/Communication
  • Licensee Role, Duties, and Responsibilities

Licensee agreed to do the following in order to bring the facility into compliance:
  • Complete and Submit the LIC 500 for the most current staff, shifts, and coverage

  • Complete and Submit the LIC 308
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GEORGIA'S GUEST HOME
FACILITY NUMBER: 500305863
VISIT DATE: 05/23/2023
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  • Complete and Submit proof of most recent training in the areas of Medication Handling, Dispensing, and Proper Documentation. Proof of submission to include name of outside vendorized trainer, topics covered with duration of training, and list of all attendees

  • Complete and submit proof of certified Administrator for this facility


Not withstanding the above statement, the Department will take the following actions:
  • The facility will continue to have additional monitoring and facility inspections to verify improvement in compliance.

  • Facility designated Administrator has agreed to enroll and enlist services from TSP

  • Failure to maintain substantial compliance outlined on LIC 9111 dated 05/22/2023 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action.


Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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