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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004748
Report Date: 09/25/2023
Date Signed: 09/25/2023 03:09:45 PM

Document Has Been Signed on 09/25/2023 03:09 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
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: 23DATE:
09/25/2023
TYPE OF VISIT:Case Management - Infectious Disease OutbreakUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Joan LitteTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA)s Jamie Ivey Canady and Albert Johnson arrived to the facility unannounced to conduct a complaint investigation visit. LPAs were greeted at the facility door by caregiver Patricia Lactaoen. Before stepping into the facilthy, LPA Ivey Canady questioned if there was Covid 19, Bed Bugs, Roaches, or Scabies at the facility. Caregiver Patricia stated no. LPAs proceeded into the facility. LPAs met with administrator Joan Little, and explained the purpose of the visit. LPAs toured the facility and LPAs observed the medication to be locked and inaccessible to residents. While conducting an interview with the administrator, facility staff, Patricia Lactaoen approached the table and informed LPAs there is one resident in the facility with Scabies. Facility Staff Patricia looked at administrator and said "it was asked if there was scabies here" For safety precautions LPAs moved the visit outdoors. LPA Ivey Canady conducted a phone interview with Joan and Joan stated Patricia Lactaoen had forgotten there was scabies in the facility when LPA Ivey Canady inquired upon arrival.


LPA Ivey Canady interviewed administrator Joan for this continuing case management regarding the Scabies outbreak at the facility. Joan stated: "R1 must have contracted scabies while we were gone at the beach house because R1 didn't have a rash before we were gone. We went to a beach house for 5 days and I took 12 residents along. I am going to quarantine all other 11 residents. They are currently at day program. LPA Ivey Canady advised Joan to alert the day program immediately and have all residents return to the facility. R1 is being treated and was sent to the doctor on 9/23/2023. LPA Albert Johnson inquired if the health department has been notified. Administrator stated the health department is currently being notified today. Administrator stated R1 is the only resident in the facility with any sign of rash.

Based on current Title 22 regulations deficiencies are being cited on 9099-D.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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Document Has Been Signed on 09/25/2023 03:09 PM - It Cannot Be Edited


Created By: Jamie Ivey-Canady On 09/25/2023 at 10:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: EMPIRE GUEST HOME
FACILITY NUMBER: 507004748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2023
Section Cited
CCR
85092.7(a)(2)

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85092.7 Staph or Other Serious, Communicable Infections (a) A licensee may accept or retain a client who has a staph or other serious communicable infection...(2) The licensee has obtained a statement from the client's physician that the infection is not a risk to other clients. This was not met as evidenced by.

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Licensse stated there will be staff training regarding Communicable Infections and the LPA will receive training log in sheet by COB 9/26/2023
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Licensee did not ensure all residents who were exposed to a resident with scabies were quarantined and cleared by a physician based on Title 22 regulations. This imposed an immediate health and safety risk to residents in care.
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Type A
09/25/2023
Section Cited
CCR80012(a)

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80012 False Claims (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This was not met as evidenced by:
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Licensee stated there will be staff training regarding how to answers the Department when there is a facility viisit and provide the LPA with a sign in sheet by COB 9/26/2023
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Licensee did not ensure staff provided correct information to the Department when asked if there was a communicable disease in the facility upon arrival. This imposed an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023


LIC809 (FAS) - (06/04)
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