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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500305863
Report Date: 05/27/2026
Date Signed: 05/27/2026 04:14:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260526090222
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: 10DATE:
05/27/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Georgia WilcombTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility is unkempt.
INVESTIGATION FINDINGS:
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~ LPA arrived to the facility to open the complaint investigation into the above allegation. LPA met with the administrator Georgia Wilcomb to explain the purpose of the visit. A previous report by the LPA outlined some areas for improvement with the cleanliness of the facility.
~ LPA made a walk through of the property for an observation, the inside is clean. there are some matresses and a lawn mower out on the lawn/gargen area. The soda trash is significantly reduced from last time in the food storage area, just 1 mostly empty cup. Lemon tree side still has 5+ pepsi cans, 5+ rotting ground fruits, 15+ cigarrete butts under the eaves. There are some ash trays out there with some limited use, LPA gave guidance to police the butts and get more buy in from the residents about using the ash trays, there is a dry grass around and its may. Many of the residents have some limitation on thier mobility, it would not be unreasonable to have 1 ashtray accessible to each outdoor seat. Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.)
~ Citation issued, a copy of the report was read and given to the administrator. Appeal rights provided, exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
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 3
Control Number 27-AS-20260526090222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) 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.
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Send a picture to the LPA when the area is cleaned up, by 6/3/26. either the LPA's phone 6193234509 or the email noel.wolfpetersen@dss.ca.gov
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This requirement was not met as evidenced by: some trash on the back porch, its pepsi cans, ciggarette butts, rotting fruit along with some items that should be put away, mattresses/a lawnmower. not following this requirement presents a risk to the clients health, saftey, or personal rights.
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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: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3