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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 12:17:27 PM


Document Has Been Signed on 04/11/2024 12:17 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: 10DATE:
04/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Georgia WilcombTIME COMPLETED:
12:30 PM
NARRATIVE
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On 04-11-2024 at 8:45 AM, Licensing Program Analysts (LPAs) Avelina Martinez and Renee Campbell conducted an unannounced visit to conduct a case management. LPA Avelina Martinez and LPA Renee Campbell met with Georgia Wilcomb and explained the purpose of today's visit.

The purpose of this visit is follow up on learned deficiencies during a complaint investigation 27-AS-20240125090756. On April 04, 2024, LPA Martinez conducted an unannounced complaint visit. During April 04, 2024 complaint visit, LPA Martinez witnessed no care staff at approximately 8:30 AM. It was learned the assigned volunteer care staff left the facility for unknown time frame. LPA Martinez called the Licensee upon arrival at facility, and resident 1 (R1) called volunteer staff 1 (VS1). VS1 arrived at the facility at approximately 9:00 AM. VS1 left the facility to complete personal errands.

As a result, the facility will be cited for not providing care and supervision to residents in care. An civil penalty shall be assessed on April 11, 2024 in the amount of $ 500.00 for the immediate health and safety risk of leaving residents alone.

Additionally, LPA Martinez was informed R1 assists resident 2 (R2) with showers. Georgia Welcomb was informed only care staff should be providing care and supervision to residents in care. Furthermore, Georgia was advised R1 is not able to oversee the facility and residents in care due to the fact that R1 is a resident.

LPA Martinez also reviewed the September 09, 2023 Non-Compliance Conference compliance (NCC) agreement and concerns. Due to recent care and supervision deficiency, the facility has not complied with NCC compliance agreement. The continued concerns are the following:
  • Facility staffing
  • Oversight of facility staff for proper care and supervision
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
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)
Page: 1 of 3


Document Has Been Signed on 04/11/2024 12:17 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: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2024
Section Cited
CCR
87468.2(4)

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87468.2(4) Additional Personal Rights of Residents in Privately Operated Facilities...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs... This requirement was not
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Licensee has implemented staffing plan. Licensee will email weekly staffing schedule to LPA Martinez by POC date 04/11/2024. Licensee provided staffing schedule to LPA Martinez during this visit. Licensee will email weekly staffing schedules until additional staff has been hired.
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met as evidence by: Based on observation and interviews on 04/04/2024 care staff 1 left the facility and left residents alone for unknown time period. When LPA Martinez arrived at the facility there were no care staff. This posed an immediate health and safety risk to residents 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 04/11/2024
NARRATIVE
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Due to immediate health and safety concerns and history of non-compliance with staffing regulations, LPA Martinez requested weekly work schedules be emailed every Monday at 8:00 starting April 15, 2024 until additional staffing has been hired.

Staffing Plan:
  1. Licensee reported they are present at the facility 40 hours per week.
  2. The Licensee has finger printed/background clearance 4 potential employees.
  3. Licensee will add VS1 on payroll, and have a set schedule.

LPA Martinez will continue to follow up with Georgia regarding staffing concerns.

As a result, of this case management, deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of this report, 809-D page, and appeals rights were provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
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
LIC809 (FAS) - (06/04)
Page: 3 of 3