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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:59:07 PM


Document Has Been Signed on 10/05/2022 02:59 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 9DATE:
10/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Georgia WilcombTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown and Dana Garcia, Associate Governmental Program Analyst (AGPA) arrived unannounced on a subsequent complaint visit on 10/5/22 at 10:00AM.

The team met with Georgia Wilcomb and stated the purpose of todays visit. The facility is licensed for a capacity of 15 residents. The team requested copies of the Official Pest Prevention Inc. invoices to include description of what type of service was provided. LPA received a copy of the Account Statement Report for dates 1/1/22 - 12/31/22 which indicated the invoice amounts and balances not the specific work that was performed. LPA observed an invoice that indicated that the facility sprayed for bed bugs on 5/24/22. The team and Administrator Georgia Wilcomb toured residents room and observed bed bugs on residents mattress on top of the bed bug covering under the sheets during this visit. The team also observed the Administrator has several "sticky traps" in the kitchen under the cabinets that contained many roaches and there was used cat food cans present in the front of the facility. The team observed that the staff in the facility was not wearing masks as mandated for infection control due to covid-19 pandemic.

Based on observations the preponderance of evidence standards has been met; therefore, the above deficiencies will be cited during this visit.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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 10/05/2022 02:59 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
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: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited

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General Food Service Requirements

The following...requirements shall apply:
All...areas shall be kept clean and free of litter, rodents, vermin and insects.
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This requirement is not met as evidenced by: Administrator did not ensure facility exterior and interior was free of litter and insects.
Based on observations the team observed flies in the kitchen area as well as roach filled traps.
This violation poses a potential health, and safety risk to residents in care.
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Type B
10/26/2022
Section Cited

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Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement is not met as evidenced by: Administrator did not ensure facility interior was safe and healthful for resident use.
Based on observations the team observed bed bugs on the residents bedding.
This violation poses a potential health, and safety risk to 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
LIC809 (FAS) - (06/04)
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