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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500309303
Report Date: 08/21/2025
Date Signed: 08/21/2025 11:20:48 AM

Document Has Been Signed on 08/21/2025 11:20 AM - 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/
DIRECTOR:		RENEE LITTLEFACILITY TYPE:
740
ADDRESS:237 S ABBIE STREETTELEPHONE:
(209) 527-2765
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY: 32CENSUS: 29DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Renee Little, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 08/21/2025, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. LPA Campbell met with Renee Little, Administrator and Sarah Rico, House Manager and explained the purpose of the visit. There are currently 29 people in residence in the facility.

The facility is a one story building licensed to serve 32 ambulatory or non-ambulatory clients, age 60 and over. It is also approved for 2 hospice residents. LPA Campbell inspected the physical plant including bedrooms, bathrooms, kitchens and common areas. LPA Campbell observed the community to be well lit, clean, free from odor and in good repair. During a tour of the community, the fire extinguishers were observed to have last been inspected on 05/06/2025 and were fully charged. Staff conducted smoke and carbon monoxide alarm tests and they were found to be functioning. The temperature for the inside of the physical plant was observed to be 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The water temperature for the resident bathrooms was measured at 118 degree Fahrenheit. There are no bodies of water present on the premises.

Food items were stored in indoor and outdoor settings and a two day supply of perishables and a seven day supply of non-perishables were observed. The refrigerator temperature was observed at 38 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit. LPA Campbell observed that a sign on the front of the refrigerator stated, "Do Not Put Anything in Here Without a Label and a Date".



NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: J & L GUEST HOME
FACILITY NUMBER: 500309303
VISIT DATE: 08/21/2025
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Throughout the physical plant, LPA Campbell observed 'See Something Say Something' posters and contact information for the Long Term Care Ombudsman.

LPA Campbell observed resident rooms 10, 11 and 13. They contained the required beds, lamps, closets and chest of drawers. Due to some residents having wheelchairs and/or other personal preferences, residents either had desks or chose to not have a night stand. LPA Campbell observed the first aid supply kit as having scissors, tweezers, thermometers and a first aid manual. Access to knives and cleaning products were found to be inaccessible to residents.

Of the 29 residents, LPA Campbell reviewed 3 of their files. For the 24 staff. 3 of their files were reviewed. All files reviewed were found to be complete.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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