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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 06/13/2024
Date Signed: 06/14/2024 10:17:40 AM


Document Has Been Signed on 06/14/2024 10:17 AM - 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: DATE:
06/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Georgia WilcombTIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/13/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to complete a case management begun on 05/23/24. LPA Campbell entered the premises to confirm if any updates to the torn rugs had been made and if staff files were complete. Upon arrival at approximately 8:35 am, LPA Campbell observed residents in their beds asleep. The rug had not been changed and still had tears.

No awake staff were observed in the dining, living room or any common areas. A resident (R1) was observed sleeping in the chair in the living room. LPA Campbell asked where staff was and the resident stated, “Linda should be around somewhere.” LPA Campbell again walked around the facility and looked in the backyard and observed no staff.

LPA Campbell walked out to the driveway of the facility to contact LPA Arielle Pascua who was consulted by phone regarding the lack of staff. Administrator and Licensee Georgia Wilcomb was then called at approximately 8:49 am and notified of the lack of staff and stated they were “Just around the corner” and would be there. LPA Campbell returned inside of the facility to await the administrator. Within a few minutes, staff member Linda Cavin walked into the facility and stated, “I had to go get my glasses so I could do the medication.” When Administrator Wilcomb was informed of why there was no staff, they stated, “Well she only lives 50 feet away.”

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 06/14/2024 10:17 AM - 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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2024
Section Cited
CCR
1568.0822(c)(3)

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1568.0822 (c)(3) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation...
3. Absence of supervision, as required by statute and regulation.
This requirement is not met as evidenced by:
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The licensee will write of statement of understanding that alert, awake staff are to be present in the facility continuously at all times. All staff will also sign a statement that they understand that they are not to leave the facility when on their shift at any time unless there is an
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Based on observation, the licensee did not ensure alert and awake staff were present in the facility which poses an immediate Health, Safety or Personal Rights risk to persons in care.
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 emergency disaster requiring the evacuation of all residents or all residents are on an outing.. The documents are then to be provided to LPA Campbell via fax or email at renee.campbell@dss.ca.gov

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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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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: 06/13/2024
NARRATIVE
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As a result of this case management, citations are issued under Title 22, Division 6. A civil penalty in the amount of $500 was issued. Due to time constraints and additional deficiencies, the Department will return to this facility to complete this case management visit. An exit interview was conducted with Georgia Wilcomb and a copy of this report was provided. Appeal rights provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3