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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 02/19/2025
Date Signed: 02/19/2025 02:26:32 PM

Document Has Been Signed on 02/19/2025 02:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GEORGIA'S GUEST HOMEFACILITY NUMBER:
500305863
ADMINISTRATOR/
DIRECTOR:		GEORGIA WILCOMBFACILITY TYPE:
740
ADDRESS:102 SOUTH G STREETTELEPHONE:
(209) 529-7872
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY: 15CENSUS: 11DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Georgia Wilcomb, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell and arrived at the facility to conduct an unannounced annual inspection on 02/19/2025.  LPA met with Georgia Wilcomb, Administrator and Licensee and explained the purpose of the visit.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve fifteen (15) non-ambulatory and ambulatory residents. Upon entry, LPA Campbell observed food on the floor and a dining table that was still sticky from the morning breakfast. The facility was free of odor. LPA Campbell observed staff take out the garbage, but when opened a few minutes later, garbage had been placed in the garbage can without a liner. Spider webs were observed on light fixtures and painters tape was still on other ceiling light fixtures. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. Of the four bathrooms, three were observed with clothing or towels on the bathroom floor and showers had not been cleaned. Administrator Willcomb stated the bathrooms had flooded yesterday and impacted the floors..Assistance with the toilet flooding was received from neighbors and equipment per the administrator was used that the facility kept on site. There are currently no bodies of water present.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers were last inspected on March 25, 2025. The smoke and carbon monoxide detectors were tested and found to be in good repair. Facility thermostat was observed at 76 degrees Fahrenheit. LPA Campbell checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit contained scissors, thermometer and tweezers. The first aid manual could not be found per the administrator. LPA Campbell requested 4 of 11 client files and 4 of 5 staff files for review. Staff files were disorganized, missing pages or did not have the folder needed to retain paperwork. The administrator had to spent more than 5 minutes finding the requested information for staff. Three of four files were not complete.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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Document Has Been Signed on 02/19/2025 02:26 PM - It Cannot Be Edited


Created By: Renee Campbell On 02/19/2025 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GEORGIA'S GUEST HOME
FACILITY NUMBER: 500305863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2025
Section Cited

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87411 (c)(1) Staff providing care shall receive appropriate training in first aid. This requirement was not met as evidenced by:
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Based on file reviews, 2 of 4 files reviewed did not have documentation of 1st aid certification.
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Type B
04/28/2025
Section Cited

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The licensee shall ensure that personnel records are maintained... Each personnel record shall contain the following information: (7) Past experience ...employers.(11) A health screening
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Based on file review, 1 of 4 files did not contain a health screening and 1 of 4 files did not have a job application or personnel record.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GEORGIA'S GUEST HOME
FACILITY NUMBER: 500305863
VISIT DATE: 02/19/2025
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Though the administrator could not find their most current Administrator Certificate, online records show that it is active. Client file organization had improved since prior visits. Toxins were made inaccessible to clients in care. Toxins are stored in the laundry room with the files.
The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 02/27/2025 by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate   
(4) LIC 610 Emergency Disaster Plan

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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