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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 05/23/2024
Date Signed: 05/23/2024 06:08:45 PM


Document Has Been Signed on 05/23/2024 06:08 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:
05/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Georgia Wilcomb, AdministratorTIME COMPLETED:
06:30 PM
NARRATIVE
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LPA Campbell arrived to the facility on 05/23/24 unannounced to follow up on prior plans of correction. LPA Campbell drove to the facility and was met by the administrator, Georgia Wilcomb, outside of the building. Upon entering the facility, LPA Campbell observed residents sitting on the patio and eating in the dining room. A podiatrist was present providing service to the residents one at a time.

LPA Campbell explained the purpose of the visit to the administer to verify completion of the plan of correction (POC) from the April 05, 2024 deficiency from the Legal Compliance meeting. According the the POC, the facility was to make significant progress in the kitchen, bathroom, and for rugs/flooring. As of 05/23/24, No progress had been made for the rugs in the hallways and living areas. Two areas of the rug are still taped down with duct tape and still provide a tripping hazard.

Staff files were also reviewed. When asked, Administrator Wilcomb stated there were only three staff working in the facility. Per Administrator Wilcomb, no volunteers are working. LPA Campbell conducted an LIC859 Staff Records Review for the three staff files. They included Steve Hardin, Administrator Wilcomb and Linda Cavin. Though the administrator mailed the requested documents to the regional office, employee files lacked CPR certification, employee rights and/or ongoing training certificates at the time of review.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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Document Has Been Signed on 05/23/2024 06:08 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: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87412(g)

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Personnel Records 87412(g) (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement is not met as evidenced by:
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Administrator will ensure that all required documents will be in individual files for each staff and resident and ready to review by 05/31/24.
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Based on record review, none of the requested documents were present in the facility as required. This poses a potential health, safety and personal rights risk to persons 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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: 05/23/2024
NARRATIVE
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Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit.
Due to time constraints, the Department will return to this facility to complete this case management visit. An exit interview was held with Georgia Wilcomb, Administrator 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: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3