500305863-4-12-2023-27-AS-CYAG-CQTRMA-20230412130821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 04/11/2023
Date Signed: 04/12/2023 01:08:28 PM

Document Has Been Signed on 04/12/2023 01:08 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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:	04/11/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Paul Steven Hardin		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Plan of Correction visit made out to this facility on 04/11/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who were met by the facility designated Administrator Paul Steven Hardin who was briefly interviewed. Current census was 9 residents. The purpose of this visit was to review the plan of corrections that were due from deficiencies that were cited on prior annual visit conducted on 03/09/2023: (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. (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. (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:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
	VISIT DATE: 04/11/2023

NARRATIVE

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(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

(c) All window screens shall be clean and maintained in good repair.

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, hand washing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or non ambulatory residents, based on the residents' needs.

(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.

(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:

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

(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.

A tour of this facility was conducted.

Deficiencies that were cited were observed to have been cleared and brought into compliance. POC clearance letters were printed and copies were given to the facility designated Administrator at this time.

No further deficiencies were observed or cited during today's POC visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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