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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:46:55 PM

Document Has Been Signed on 11/13/2024 03:46 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/
DIRECTOR:		GEORGIA WILCOMBFACILITY TYPE:
740
ADDRESS:102 SOUTH G STREETTELEPHONE:
(209) 529-7872
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
11/13/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Georgia Wilcomb, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11/13/24, Licensing Program Analyst Renee Campbell conducted a Case Management visit for R1 who was experiencing a possible medical incident. LPA Campbell met with Licensee Georgia Wilcomb and explained the purpose of the visit.

During visit, R1 reported she wasn’t feeling well to Georgia Wilcomb, Licensee. R1 was overheard stating she was worried about the bright blood in her stools but did not want to go to the doctor. Later, a shout of pain was heard from her direction. Licensee Georgia Wilcomb investigated and reported to LPA Campbell that R1 was experiencing abdominal pain and still did not want to go to the doctor. The licensee stated that R1’s primary doctor suggested she go to the emergency room but R1 refused. After speaking with R1, they continued to refused medical intervention. LPA Campbell then suggested that the licensee call 911 for assessment. LPA Campbell observed emergency personnel arriving within 5 minutes at approximately 1:54 pm. Once they arrived, R1 refused to let them assess. Emergency personnel then left after reporting that R1 refused to go to the emergency room or submit to assessment. No documentation was provided to the facility or R1. LPA Campbell suggested that Licensee Wilcomb check on R1 and log her status to ensure she is alert and oriented.

Lisa RiosTELEPHONE: (916) 969-9685
Renee CampbellTELEPHONE: (916) 206-6380
DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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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: 11/13/2024
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LPA Campbell reviewed the LIC 602 for R1. Their Primary Diagnosis is listed as Syncope and Collapse and their Secondary Diagnoses was Hyperlipidemia. R1 is ambulatory, able to leave the facility alone and experiences depression. The licensee was advised to continue checking on R1 to ensure they are alert and oriented
An exit interview was held and a copy of this report was left with facility staff.

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SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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