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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:30:27 PM


Document Has Been Signed on 04/11/2024 12:30 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:
04/11/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Georgia Wilcomb, LicenseeTIME COMPLETED:
01:00 PM
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On 04/11/24, Licensing Program Analyst (LPA) Renee Campbell and LPA Avelina Martinez arrived to the facility to review the requirements as agreed to in the prior Noncompliance Conference on 03/25/2024. As discussed at the NCC Conference, licensee has agreed to provide corrections for the following issues by the following dates:
      1. Licensee will provide copies of Linda Cabin's trainings by 4/12/24. Per Licensee, Georgia Wilcomb, staff will need a month to complete their training and licensee will provide proof of payment and vendor's name by 04/18/24.

      2. Licensee will provide proof of administrator renewal resubmitted, and proof that they have paid for renewal of the administrator certificate in the form of a receipt and/or a copy of a cleared check by 04/05/2024. Currently, proof of the cleared check is pending. LPA Campbell will verify if a copy of the administrator renewal application has arrived via certified mail once back in the office.

      3. Verify that everyone in the unlicensed facility has been assessed within 15 days after the NOVL was issued on 03/25/24.
      Per the licensee, the one resident who was in need of Care and Supervision has been moved to the licensed facility next door as of 04/05/24 and was observed in the facility by LPA Avelina Martinez on 04/11/24.

    Per California Code of Regulations, Title 22 there were no deficiencies cited during today's visit. An exit interview was conducted, and a copy of this report was left at the facility. 



SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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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