500305863-10-5-2022-27-AS-KHOS-CKDQLX-20221020121641

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 500305863
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:01:09 PM

Unsubstantiated

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
09/02/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20220902143210

FACILITY NAME:	GEORGIA'S GUEST HOME		FACILITY NUMBER:	500305863
ADMINISTRATOR:	GEORGIA WILCOMB		FACILITY TYPE:	740
ADDRESS:	102 SOUTH G STREET		TELEPHONE:	(209) 529-7872
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY:	15	CENSUS: 9	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Georgia Wilcomb		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility has vermin.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown and Dana Garcia, Associate Governmental Program Analyst (AGPA) arrived unannounced to conclude a complaint investigation on 10/5/22 at 10:00AM.

The team met with Georgia Wilcomb and Paul Steven Hardin, Administrator 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 along with specific work that was performed. The team interviewed resident #1 (R1) - (R4) during this visit. The team toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The team observed there are 3 cats around the perimeter of the facility which are not allowed inside. R1 and R2 both stated that they observed mice in the kitchen area. However, R3 and R4 both stated they did not observe any mice in the facility.

Unsubstantiated

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220902143210

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: 10/05/2022

NARRATIVE

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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. The team also observed the Administrator has several "sticky traps" in the kitchen under the cabinets that contained many roaches. These deficiencies will be addressed on a Case Management visit.

Based on lack of evidence the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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