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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 02/12/2024
Date Signed: 02/12/2024 04:15:43 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/12/2024 04:15 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: 9DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Georgia Wilcomb, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to this facility to conduct an annual inspection on 02/12/2024 at 9:15 am. LPA met with Stephen Hardin, House Manager and Georgia Wilcombe, Administrator and stated the purpose of today’s visit. LPA Campbell inspected the physical plant to ensure compliance with Title 22 regulations. The facility is licensed for 15 ambulatory and nonambulatory residents over 60.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. Though a ramp was observed for the entrance of the facility, no ramp was found through the back door to the patio and backyard. LPA Campbell also observed a burnt pile of wood and oranges. When asked about it, the House Manager stated that a client dumped the items from the yard there. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. While touring the office, a See Something Say Something poster was seen propped against a wall where it could not be viewed by residents or visitors. Per Licensee, the poster had become wet due to a now repaired washing machine. The licensee returned the poster to the wall during today's visit.

The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 107 *F which is within the required range of 105-120*F. LPA observed a fire extinguisher(s) that was last inspected on 03/13/2023 and smoke and carbon monoxide detectors that were tested.
Per California Code of Regulations (CCR), no deficiencies were observed. An exit interview was conducted, and a copy of the report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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