500305863-10-17-2023-27-AS-CYAG-CWPUYU-20231017160032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 09/15/2023
Date Signed: 10/17/2023 04:00:38 PM

Document Has Been Signed on 10/17/2023 04:00 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 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: 9	DATE:	09/15/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Paul Steven Hardin		TIME COMPLETED:	01:00 PM

NARRATIVE

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A Non Compliance Conference (NCC) was conducted on this day, 09/15/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non Compliance Conference meeting was to follow up with the facility after the Informal Conference was last held on 05/23/2023. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Charlie Yang, and Facility Designated Administrator Steven Paul Hardin with Licensee Georgia Wilcomb.

The Non Compliance 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 by COB 09/22/2023

Complete and Submit the LIC 308 by COB 09/22/2023

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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: 09/15/2023

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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 by COB 09/22/2023

Complete and submit proof of certified Administrator for this facility by COB 09/22/2023

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

Complete and submit plan of admission for all residents by COB 09/22/2023

Failure to maintain substantial compliance outlined on LIC 9111 dated 09/15/2023 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action.

Exit Interview

Licensee/Administrator signature on file.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 04:00 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/15/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	adequate attention to the management and administration of the facility as specified in this section. This facility was found to be deficient as evidenced by not having a certified administrator on file at this time. This presented an immediate threat to the Health, Safety, and Personal Rights of the residents in care.	8 9 10 11 12 13 14
Type A 09/29/2023 Section Cited CCR87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This facility was found to be deficient as evidenced by having worn out, torn, and	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	missing carpet throughout this facility. This presented an immediate threat to the Health, Safety, and Personal Rights of the 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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