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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500309303
Report Date: 11/02/2023
Date Signed: 11/02/2023 05:09:32 PM


Document Has Been Signed on 11/02/2023 05:09 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:J & L GUEST HOMEFACILITY NUMBER:
500309303
ADMINISTRATOR:ANITA NIELFACILITY TYPE:
740
ADDRESS:237 S ABBIE STREETTELEPHONE:
(209) 527-2765
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:32CENSUS: 29DATE:
11/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Renee Little, AdministratorTIME COMPLETED:
05:15 PM
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On 11-02-23 at 3:00 pm, Licensing Program Analysts (LPAs) Renee Campbell arrived unannounced to conduct a case management visit regarding an incident which occurred on 10/03/23. LPA Campbell met with Administrator Renee Little and explained the purpose of the visit. LPA requested facility file documentation including physician's report for resident 1 (R1) and hospital discharge paperwork for R1. LPA also conducted facility observation and reviewed incident report dated 10-04-23. Additionally, LPA conducted brief interview with Administrator.

Based on incident report and interviews, the following was determined: R1 was taken to the hospital on 09/01/23 and evaluated. Based on discharge paperwork reviewed, R1 had contracted pneumonia and received antibiotics for treatment. R1 went to the hospital again due to a pressure wound on 10/03/23 and passed away that afternoon at approximately 4:42 pm. Per the death certificate, R1’s death was due to sepsis and pneumonia was listed as a contributing factor.

As a result of this case management, no citations are issued today. An exit interview was conducted with Renee Little and a copy of this report was provided to Renee Little.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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