500305863-5-18-2023-27-AS-LKIG-CSBLF7-20230530084239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 500305863
Report Date: 05/03/2023
Date Signed: 05/18/2023 05:19:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
11/30/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221130164942

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: 10	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Steven Paul Hardin		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff are not addressing resident's rash as necessary.

Staff handled resident in a rough manner, causing ear damage.

Staff do not accord resident dignity.

Staff do not ensure that resident(s) have clean linens.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 05/03/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who were met by the facility designated Administrator Steven Paul Hardin.
Current census was 10 residents.
The purpose of this visit was to deliver the findings from this complaint investigation for the above allegations at this time.
Based on interviews and information gathered during the course of this investigation, it was learned that facility staff and potential residents were having personal issues outside of providing adequate care and supervision at this time. From these interactions, these relationships were strained with accusations going back and forth without any real basis for validity.
Facility residents, overall, felt that they were being treated with dignity and respect by the facility staff. Facility residents felt that they could approach the facility staff if they had any issues or concerns without prejudice or fear of retaliation if their concerns were voiced.
A review of the linen closet was conducted and this LPA observed that there was a sufficient supply of

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
11/30/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221130164942

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: 10	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Steven Paul Hardin		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility toilet(s) are in disrepair.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 05/03/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who were met by the facility designated Administrator Steven Paul Hardin.
Brief interview conducted with the facility designated Administrator at this time.
Current census was 10 residents.
The purpose of this visit was to deliver the findings from this complaint investigation for the above allegations at this time.
Based on a tour of the facility restrooms and a review of the facility physical plant, it was observed by this LPA that certain restrooms were in need of repair/replacement at this time.
It was observed that certain toilets were having issues with flushing and draining properly.
Based on interviews with the facility staff, it was learned that they were made aware of the toilets in need of repair/replacement and were in the process of sorting out this issue.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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-20221130164942

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/03/2023

NARRATIVE

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As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 27-AS-20221130164942

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/04/2023 Section Cited CCR 87303(e)(6)	1 2 3 4 5 6 7	Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, hand washing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or non ambulatory residents, based on the residents' needs.	1 2 3 4 5 6 7	Citations were already issued on annual visit dated 03/09/2023 and POC already completed. No additional POC required at this time.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that there were holes in the walls, issues with the plumbing fixtures, and toilets that needed to be repaired/replaced which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20221130164942

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/03/2023

NARRATIVE

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bedsheets, blankets, and towels made available and able to meet the needs of the residents at this time.
It was learned that facility staff did not enforce the shower schedule on the facility residents but used it as a guide for residents to avoid confusion and everyone trying to shower all at the same time.
It was learned that facility staff would never turn away a resident attempting to shower but had more difficulty attempting to get residents to go take a shower and maintain proper hygiene.
Facility residents would often times develop skin sores and irritation but hide these symptoms from the facility staff. Most of these issues stemmed from residents not maintaining proper hygiene and not changing clothes and bed sheets on a regular basis.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited during today's complaint visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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