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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500305863
Report Date: 03/02/2022
Date Signed: 03/22/2022 03:40:04 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2021 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211105123859
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:
03/02/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Paul Steve HardinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not keep the facility free from pests

Staff are not properly maintaining a resident's room

INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/02/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Paul Steve Hardin. A brief interview was conducted with the facility designated Administrator.
Current census was 11 residents.
The purpose of this complaint visit was conducted to complete the investigation and present the findings to the facility designated Administrator at this time.
Based on a physical plant tour of this facility, it was observed that the facility did have an issue with flies being present. It was observed that flies were present in the common areas as well as the resident rooms and restrooms.
Based on a review of the resident bedrooms, it was observed that staff are not maintaining and making sure that the bedrooms were kept clean and free of any debris and pests. It was observed that bedding needed to be changed out with a need for housekeeping as well.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2021 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211105123859

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:
03/02/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Paul Steve HardinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not providing nutritious meals to residents

Staff do not provide adequate care and supervision to residents while in care

Uncleared adults are present in the facility

Staff speak inappropriately towards a resident while in care

Facility toilets are in disrepair
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/02/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Paul Steve Hardin. A brief interview was conducted with the facility designated Administrator.
Current census was 11 residents.
The purpose of this complaint visit was conducted to complete the investigation and present the findings to the facility designated Administrator at this time.
Based on a physical plant tour of this facility, it was observed that the facility food supply was sufficient to meet the 2-day perishable and 7-day nonperishable quantity requirements at this time. It was observed that fruits and a variety of vegetables were present and served during most meals for the residents. It was learned that (3) meals were served with snacks given, and made available, to the residents throughout the day.
Based on interviews conducted with the facility residents, it was learned that meals were served timely and the portions that were provided were sufficient and able to meet the needs of the residents at this time. It was learned that additional portions were provided for residents who wanted to eat more than what was originally served with the first tray.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20211105123859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 500305863
VISIT DATE: 03/02/2022
NARRATIVE
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Based on interviews conducted with facility residents, it was learned that they are able to come and go as desired throughout the day. It was learned that residents are expected to follow all house rules and comply with medication requirements in order to be compliant. It was learned that staff are present throughout the day and residents are able to locate one for assistance at any time of the day and night. It was learned that outings were provided and residents did participate in them but due to the pandemic these have been temporarily halted at this time.
Based on interviews conducted with facility residents, it was learned that they were treated and spoken to with respect to their personal rights. It was learned that they did not feel intimidated by the facility staff nor were they fearful of any ill treatment. For the most part, facility residents agreed with the level of care and the level of mutual respect being exchanged at this time. They admitted that there were good and bay days between residents and staff but did not feel, in any way, that they felt threatened when these types of incidents took place.
Based on a review of the facility roster and the LIS 536, all facility personnel were properly fingerprint cleared and associated to this facility at this time. It was learned that there were (3) shifts available for staff working the morning, afternoon, and NOC shift. All staff members listed on the LIC 500 were observed to be present on the LIS 536 and cleared at this time.
Based on a physical plant tour of this facility and it's restrooms, it was observed that the toilets were in working order and in compliance at this time. It was observed that the toilets were able to be flushed, water basin filled back up, and remained full until the next use.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20211105123859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 500305863
VISIT DATE: 03/02/2022
NARRATIVE
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As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

A copy of the Appeal Rights were printed, with a copy, left with the facility designated Administrator after discussing them with this LPA at this time.

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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20211105123859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This facility was found deficient as evidenced
by the presence of flies throughout this
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The facility representative stated that a pest control plan will be completed and submitted into CCL detailing the type of service that will be contracted and actual service date. A statement of correction will be completed and submitted into CCL by the due date of 03/28/2022.
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facility in the common areas, resident bedrooms, and restrooms. This posed a potential threat to the overall health, safety, and personal rights of all residents in care.
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Type B
03/28/2022
Section Cited
CCR
87464(f)(4)
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Basic Services
Basic services shall at a minimum include:
Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608.
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The facility representative stated that a housekeeping schedule will be completed and submitted into CCL for all residents and their service needs along with a statement of correction by the due date of 03/28/2022.
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This facility was found deficient as evidenced by the staff not maintaining and making sure that the bedrooms were kept clean and free of any debris and pests. It was observed that bedding needed to be changed out with a need for housekeeping as well. This posed a potential threat to the overall health, safety, and personal rights of all residents 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5