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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 03/21/2022
Date Signed: 03/22/2022 02:43:40 PM


Document Has Been Signed on 03/22/2022 02:43 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 11DATE:
03/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Paul Steve HardinTIME COMPLETED:
03:30 PM
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Unannounced Plan of Correction visit made out to this facility on 03/21/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Paul Steve Hardin who was briefly interviewed.
Current census was 11 residents.
The purpose of this plan of correction visit was to make sure that the deficiencies which were cited on a previous visit dated on 03/02/2022 were properly addressed and brought into compliance at this time.

1) Facility designated Administrator stated that a plan for replacement for the common rooms, replaced with laminate flooring, and resident bedrooms, replaced with new carpet, will be completed and submitted into CCL by the due date. A plan of the start date and end date will be submitted into CCL with receipt of all flooring materials included as well.

A plan of correction was submitted with a date for contracted work to take place for the flooring throughout this facility.

2) The facility designated Administrator stated that all window screens will be reviewed and if any are ripped or torn, in any way, will be replaced/repaired with proof of correction submitted into CCL by the due date.

A plan of correction was submitted with a date for contracted work to take place for the replacement of the window screens throughout this facility.

There were no deficiencies observed or cited during today's plan of correction visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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