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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 07/29/2024
Date Signed: 07/29/2024 02:28:33 PM


Document Has Been Signed on 07/29/2024 02:28 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: 8DATE:
07/29/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
02:45 PM
NARRATIVE
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On 07/29/24, Licensing Program Analyst (LPA)and LPA Avelina Martinez arrived unannounced to verify the facility has completed the requirements as discussed during an NCC Conference on 03/15/24. Upon entry, LPA Campbell observed a kitchen table with food and oils that needed to be cleaned before use.

LPA Campbell conducted a tour of the facility and observed that the floors had been replaced throughout the dining room and hallways. A camera was observed in the living room. Licensee Georgia Wilcomb reported that they did not work. Images were taken of pests on the floor near the kitchen. No smoke alarm was observed in one of the bedrooms. Another bedroom still had painters’ tape around the sprinklers and lights. Chemicals, power tools, paint and debris from a recent paint job were observed in the dining room, patio and in the front of the facility. The fire extinguishers were on the floor and not braced on the wall.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. 



If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed.  A copy of their rights are provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, 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: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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 07/29/2024 02:28 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: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requiremet is not met as evidenced by:
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During visit, maintenance staff hung up the smoke detector.
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Based on observation, no smoke alarm was found in a client's bedroom which poses an immediate health, safety or personal rights riks to persons in care.
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Type B
08/09/2024
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. ... for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Facility will create a plan to maintain a clean, safe and sanitary facility in good repair at all times after completing work at the end of the day.
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Based on observation, roaches were observed on the floor, chemicals, debris and powertools were observe as accessible to clients and fire extinguishers were on the floor instead of being braced on the wall.
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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: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2