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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 08/17/2023
Date Signed: 08/29/2023 09:58:08 AM


Document Has Been Signed on 08/29/2023 09:58 AM - 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:
08/17/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Steven Paul HardinTIME COMPLETED:
03:00 PM
NARRATIVE
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Case management visit made out to this facility on 08/17/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Steven Paul Hardin, who was briefly interviewed.
Current census was 12 residents.
The purpose of this visit was to follow up with this facility and conduct the quarterly visits as outlined in the Informal Conference that was conducted on 05/23/2023.
Brief tour of this facility was conducted.
A conversation was conducted with the facility designated Administrator in regards to the physical plant of this facility. Also this LPA held a conversation with the facility designated Administrator about the current status of a certified Administrator for this facility and the progress of certification at this point in time.
In addition, this LPA was present to request some forms and documents related to an ongoing investigation at this time.
The following was requested by this LPA:

Admission Agreement for R1

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

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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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