500305863-5-18-2023-27-AS-LKIG-CSBLFU-20230530084343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 500305863
Report Date: 05/03/2023
Date Signed: 05/18/2023 05:37:15 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
12/28/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221228093649

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:	12:30 PM
MET WITH:	Steven Paul Hardin		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff are not administering medications as prescribed.

Staff are having resident in care dispense medications.

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 conducted, it was learned that medications were dispensed to all facility residents in a timely manner. Prescribed, as well as PRN medications, were dispensed according to physicians' orders. It was learned that facility resident medications were never missed and given by facility staff who were trained and documented as such.
Based on interviews, facility residents felt assured that they were receiving their medications by the facility staff who were diligent about handling, dispensing, and documentation in accordance with the law.
It was learned that facility residents did not substitute for facility staff and were not allowed to handle and dispense resident medications.

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)

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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
12/28/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221228093649

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:	12:30 PM
MET WITH:	Steven Paul Hardin		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility stove is 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.
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 observation, it was learned that the stove in the kitchen area was not functional and did not work for a few days around the Thanksgiving holiday period. Facility staff, and the facility Licensee, had to purchase meals outside of this facility and no cooking was able to be done for a few days. It was learned that the facility Licensee still put on a Thanksgiving meal without the use of the stove and made sure that there were food items and portions sufficient to meet the needs of the residents at that time.
It was learned that this facility, specifically the facility designated Administrator, was made aware of the facility stove being in disrepair and replaced it shortly thereafter rather than attempting to fix it. This avoided the issue of it breaking down again and requiring additional repairs in the future.

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)

Page: 2 of 4

Control Number 27-AS-20221228093649

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 allegation 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

Citations were already issued, with Plan of Correction, on prior annual visit dated on 03/09/2023. No additional deficiencies were cited during today's complaint visit.

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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Control Number 27-AS-20221228093649

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 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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