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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 03/25/2024
Date Signed: 03/29/2024 01:17:36 PM


Document Has Been Signed on 03/29/2024 01:17 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: 14DATE:
03/25/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Georgia Wilcomb, LicenseeTIME COMPLETED:
05:30 PM
NARRATIVE
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A Non-Compliance Conference (NCC) was conducted on this day, 03/25/2024, 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 Non-Compliance Conference was last held on 09/15/2024. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Renee Campbell, Teresa Alvarez, Patient Rights, Melissa Flaherty, LTC Ombudsman Coordinator and Licensee/Administrator 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:
  • Status of building and ground improvements.
  • Use of 911 as a non-emergency method of transportation to medical care and to replace staff instead of lifting uninjured residents off the floor.
  • Documentation of Administrator renewal
  • Clients in need of a higher level of care in an unlicensed facility, on neighboring property.
  • Training and clearance for all staff

Licensee agreed to do the following in order to bring the facility into compliance.

  • Update on facility building improvements.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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: 03/25/2024
NARRATIVE
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  • No longer use 911 for non-emergencies and provide transportation to doctor’s appointments as needed.
  • Send documentation of administrator renewal via certified mail to include: proof of classes and units taken, receipts for fees paid.
  • Copies of training and clearance for all staff.
  • Needs and assessment plans for neighboring room and board, including allowing licensing to inspect and determine residents don’t need care and supervision.

Exit Meeting.

Licensee / Administrator signature on file.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2024 01:17 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
87404(d)(2)

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87404 Administrator – Qualifications and Duties (d)(2) The administrator shall have ... Knowledge of and ability to conform to the ...regulations. This requirement was not met as evidenced by
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The Administrator will require all future residents of the unlicensed facility to provide a physicians report that confirms a resident requires no assistance with medication or acivities of daily living by POC date.
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Based on LPA Martinez’s interview , R1 stated he needs help with his activities for daily living. R1 needs a higher level of care than he is receiving at licensee’s unlicensed facility. Which poses an immediate health, safety or personal rights risk to persons in care.
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R1 will be moved to the licensed facility next door immediately by 4/05/2024
Type B
04/30/2024
Section Cited
CCR87307(d)(2)

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 87307 (d)(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on observation, interviews and record
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Administrator states that by the next NCC meeting, significant process will have been made in the kitchen, bathroom, and for rugs/flooring.
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reviews, the licensee has not begun improvements to ensure facility is clean safe, sanitary and in good repair. This poses a potential health, safety or personal rights risk to persons in care.
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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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/29/2024 01:17 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
HSC
1569.69

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Employees assisting...with...medi- cation; training requirements (B) Two years...experience,.. as an administrator ...during which time the individual has acted in compliance with applicable regulations.
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Licensee will utilize training from vendor to mainting medication training requirements. Licensee wll provide a training plain with vendor names and class topics by POC date.
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This requirement was not met as evidenced by: Based on observa- tion, interviews and record review ,the licensee provided training to an employee while not in substan- tial compliance with applicable regulations.
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Type B
04/19/2024
Section Cited
HSC1533

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Section 1533 ..any authorized ... employee,... State Department of Social Services may, enter ...any place providing ..care and .. services .. to prevent a violation of, any provision of this chapter.
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Licensee will replace the lock and obtain a new key for the unlicensed facility and be available within the hour to allow access by POC date.
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This requirement was not met as evidenced by: Based on obser- vation, licensee did not ensure the unlicensed facility was accessible to authorized employees of the State Dept of Social Services.
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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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4