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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 05/01/2024
Date Signed: 05/01/2024 03:56:33 PM


Document Has Been Signed on 05/01/2024 03:56 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:
05/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Georgia Wilcomb, AdministratorTIME COMPLETED:
04:15 PM
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On 05/01/24, Licensing Program Analyst Renee Campbell arrived to the facility unannounced and met with Administrator Georgia Wilcomb to conduct a case management. LPA Campbell reported to Administrator Wilcomb the purpose of the visit.

The purpose of the visit is to follow up on substantiated allegation from 04/11/24 under complaint 27-AS-20240125090756. On 04/11/24, LPA Avelina Martinez substantiated allegations that unlicensed care was being provided at 32 South G St, and required the licensee to move R1 to this facility where they could obtain a higher level of care.

LPA Campbell requested the file for R1 and Administrator Wilcomb provided the following documents:
  • Preplacement Appraisal
  • Client Personal Property and Valuables (with clothes listed)
  • Appraisal/Needs and Services Plan
  • Personal Rights form (signed)
  • Identification and Emergency Information
  • Consent for Medical Treatment
  • Admission Agreement form (signed)


Per the administrator, the 602 will be completed by the facility physician, Dr. Josh Kemei by 05/10/24 at the latest. If the physician fails to abide by this appointment, the administrator will call to make an office appointment between the doctor and R1 for a face to face meeting with R1 and report the new date to LPA Campbell. A copy of this report was left with the facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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