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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 03/29/2024
Date Signed: 03/29/2024 01:18:25 PM


Document Has Been Signed on 03/29/2024 01:18 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: DATE:
03/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Georgia Wilcomb, LicenseeTIME COMPLETED:
01:30 PM
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On 03/29/24, at approximately 9 am, Licensing Program Analyst (LPA) Renee Campbell arrived to facility to go over the last NCC meeting reports and obtain signatures. LPA Campbell met with Licensee Georgia Wilcomb and explained the purpose of the visit.

Upon entry of the facility, LPA Campbell observed one resident sitting in a wheelchair under a carport. Another resident was observed eating cereal in the dining room with the lights off until another resident came and turned them on. Clients either watched TV in the common living room or remained in their rooms.

LPA Campbell reviewed the NCC Meeting notes with the licensee and during the discussion, Licensee Wilcomb confirmed that Code Enforcement had been unable to access the Unlicensed Facility during a prior vist and that she planned to call to schedule an appointment with them to come on 04/05/24 when they could return. The licensee suggested several ways that she could continue to help residents living in the unlicensed facility by providing frozen meals, helping them get them get food stamps or providing a physician for health screenings. Licensee also stated that the same residents were independent. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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