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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 02/16/2024
Date Signed: 02/16/2024 05:07:01 PM


Document Has Been Signed on 02/16/2024 05:07 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:GEORGIA WILCOMBFACILITY TYPE:
740
ADDRESS:102 SOUTH G STREETTELEPHONE:
(209) 529-7872
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:15CENSUS: 10DATE:
02/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Georgia Wilcomb, AdministratorTIME COMPLETED:
05:15 PM
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On 02/16/24, LPA Renee Campbell arrived to the facility to conduct a case management regarding areas of concern discussed during a Non-Compliance Conference conducted on 09/15/2023. The facility was to complete the following tasks and have the following items present on the premises.

· Complete and Submit the LIC 500 for the most current staff, shifts, and coverage


· Complete and Submit the LIC 308
· 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
· Complete and submit proof of certified Administrator for this facility

The licensee was able to provide the LIC 500 and LIC 308.

Of the four staff members, only S4 had the certificates with the name of the vendor available. The topics covered under each subject was not available per the Administrator. LPA Campbell requested that the vendor be contacted for the topics covered for each class under any vendor who provided training on Medication Handling, Dispensing and Proper Documentation.

One staff member (S3) was trained by the administrator who created a certificate for the staff member. The administrator (S1) and a pending administrator (S2) stated that the training was provided under their administrator training.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GEORGIA'S GUEST HOME
FACILITY NUMBER: 500305863
VISIT DATE: 02/16/2024
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LPA Campbell conducted a tour of the facility to confirm completion of tasks from the Facility Annual, Technical Assistance consult completed on 2/12/24. The licensee has cleared the backyard debris, completed the install of the new rug, printed out the FPCL for the administrator and included the signed employee rights form for each staff member.

At this time, the administrator will also provide fingerprint clearance for the rest of her staff (LPA Campbell confirmed online that all staff were cleared beforehand.) and verify their medication training with the vendor and obtain the list of topics included in the training, including the administrator training.

Per the California Code of regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited. Exit interview held with Administrator, copy of report left at facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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