Community Care Licensing

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
	VISIT DATE: 03/09/2023

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type A

Section Cited

CCR

87303(f)(2)

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that syringes and lancets were left out in a kitchen cabinet that was unable to be secured making them accessible to all facility staff and residents alike which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all syringes and lancets will be stored and maintained in a locked cabinet at all times to make them inaccessible to all facility residents at all times. A statement of correction, along with photo taken as proof of removed syringes and lancets, will be completed and submitted into CCL by the due date of 03/10/2023.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type A

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [5] facility resident files did not have the required TB clearance which posed immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all facility staff will be properly cleared for TB with the corresponding document, LIC 503, to be updated and completed. A statement of correction, along with copies of the updated LIC 503 will be completed and submitted into CCL by the due date of 03/10/2023 for review by this LPA.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type A

Section Cited

HSC

1569.618(b)

(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [2] facility designated Administrators' certificates were expired and no proof of updated certificates were made available for review at the time of this visit which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that the most updated information pertaining to this facility designated Administrator will be updated and submitted into CCL for review by this LPA along with a statement of correction.

Type A

Section Cited

CCR

87412(a)(11)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [5] facility resident files did not have the required health screening documents which posed immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all facility staff will be properly cleared for their health screening, LIC 503, to be updated and completed. A statement of correction, along with copies of the updated LIC 503 will be completed and submitted into CCL by the due date of 03/10/2023 for review by this LPA.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type A

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [4] out of [5] facility resident files did not have the required current First Aid training which posed immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all facility staff will be properly trained in First Aid with updated and completed certificates. A statement of correction, along with copies of the updated First Aid certificates will be completed and submitted into CCL by the due date of 03/16/2023 for review by this LPA.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87303(c)

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above since there were several window and door screens that were in need of repair/replacement due to having holes, rips, or tears in them which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all window and door screens will be reviewed and any of them that contained any holes, rips, or tears will be repaired/replaced as necessary. A statement of correction will be completed, along with photos of the updated window and door screens, to be submitted into CCL by the due date.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type B

Section Cited

CCR

87303(e)(6)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that there were holes in the walls and items that needed to be repaired/replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all restroom walls will be repaired to remove all holes and physical plant issues within them. A statement of correction, along with photos of the repairs that were completed, will be completed and submitted into CCL for review by this LPA.

Type B

Section Cited

HSC

1569.618(c)(4)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above since resident bedroom furniture and furnishings were in need of repair. Drawers were missing handles, of off the rails and closet doors were off the rails or very difficult to slide open when needed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that the resident bedroom furniture and furnishings will be reviewed and repaired/replaced as necessary to make sure that they are in good repair at all times. A statement of correction, along with photos of the repaired/replaced furniture/furnishings, will be completed and submitted into CCL by the due date of 03/16/2023.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type B

Section Cited

CCR

87411(d)

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [5] out of [5] staff files did have contain the required updated annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all facility staff providing care and supervision to the residents will receive the required updated Annual training, with corresponding number of hours, and have proof of training within the facility staff records. A statement of correction, along with copies of staff training topics and hours, will be completed and submitted into CCL by the due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type B

Section Cited

CCR

87555(b)(27)

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that kitchen cabinets, drawers, and storage units were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all kitchen cabinets and drawers will be reviewed and any that needed to be repaired/replaced will be corrected and brought into good repair. A statement of correction, along with photos of updated kitchen cabinetry, will be completed and submitted into CCL by the due date.

Type B

Section Cited

CCR

87555(b)(29)

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that kitchen dishes, cookware, and utensils needed to be cleaned and maintained in a sanitary condition at all times which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated that all kitchen dishes, cookware, and utensils will be reviewed and any that needed to be repaired/replaced will be corrected, cleaned, and sanitized. A statement of correction, along with photos of updated kitchen dishes, cookware and utensils will be completed and submitted into CCL by the due date.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023

Document Has Been Signed on 03/10/2023 03:23 PM - It Cannot Be Edited

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Type B

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [5] out of [5] resident files which did not have an updated and completed Medication Administration Record which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Facility designated Administrator stated all resident files, with accompanying Medication Administration Record (MAR), should be updated and completed at all times. A statement of correction, along with copies of the updated Medication Administration Record (MAR), will be completed and submitted into CCL for review by this LPA by the due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023