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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004748
Report Date: 12/15/2022
Date Signed: 12/16/2022 10:59:59 AM

Document Has Been Signed on 12/16/2022 10:59 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:EMPIRE GUEST HOMEFACILITY NUMBER:
507004748
ADMINISTRATOR:JOAN LITTLEFACILITY TYPE:
735
ADDRESS:101 SOUTH G STREETTELEPHONE:
(209) 522-1441
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY: 23CENSUS: DATE:
12/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Joan LittleTIME COMPLETED:
12:30 PM
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Unannounced case management visit made out to this facility on 12/15/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Joan Little, who was briefly interviewed at this time.
Current census was 21 residents, of which, 17 were out at their respectable day programs at this time.
The purpose of this visit was to follow up on an Incident Report that was submitted into CCL in regards to the death of R1.
A review of the facility file for R1 and corresponding notes were reviewed. Copies of witness statements during the incident was given to this LPA at the time of this visit.

There were no deficiencies observed or cited during today's case management visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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