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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004748
Report Date: 07/15/2026
Date Signed: 07/15/2026 03:46:07 PM

Document Has Been Signed on 07/15/2026 03:46 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:EMPIRE GUEST HOMEFACILITY NUMBER:
507004748
ADMINISTRATOR/
DIRECTOR:
JOAN LITTLEFACILITY TYPE:
735
ADDRESS:101 SOUTH G STREETTELEPHONE:
(209) 522-1441
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY: 23CENSUS: 22DATE:
07/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Joan LittleTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst, LPA Noel Wolf Petersen, arrived unannounced to the facility to conduct a annual inspection. LPA Met with licensee/administrator Joan Little and Licensee Doug Little to explain the purpose of the visit. Empire guest home is a 22 bed 4 bath, adult residential facility taking clients between 18-59.

Phyical inspection was completed, including the kitchen, bedrooms, bathrooms, exterior, and evacuation route gate. the facility is clean, the traffic areas are clean and unobstructed.

Kitchen has adequte storage space for sharps, toxics, and medications. there are 2 days perishable food and 7 days non perishable food. The employee with thier primary responsibility as designated to handle meal prep, menu planning, etc is Mark "Doug" Little.

Bedrooms- bedrooms have adequate hardware and furnishings. LPA gave guidance to check the facility beds for plastic/rubber matteress encasements.

Bathrooms: adequate hardware is 10 persons per bath, and 6 persons per toilet and wash basin. ratios are a little tight with regard to toilets. a porta potty exists in the back lot, unclear if used. one bathroom has a hair washing station.

Common/exterior areas have plenty of space for activities.

Evacuation route- no gate, the front and side doors open to a largely empty lot used for storage and volleyball. no obstruction to the road. Continued on C page.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2026
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: EMPIRE GUEST HOME
FACILITY NUMBER: 507004748
VISIT DATE: 07/15/2026
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Medication- 2 residents medication were checked at random. the Licensee has adopted a hybrid of Alcomy and a physical log. 1 of 2 residents had a weekend away, where the drugs went into their custody while they were away from the facility. LPA asked for supportive documentation and the notes section details when the client left and came back but not a distribution of the medication. PRN/Refusal/Destruction documentation has some documentation but it is sparse(2019,2020, 2022), LPA was given the explanation by the administrator that not a lot of participants make use of their PRNs. LPA's gave guidance recommending a staff wide training to refresh on t22 documentation procedure, and the facility's own internal documentation procedure, particularly if they are moving towards a fully electronic record.

Fire extinguishers are dated 11/4/26. Smoke/CO detectors are functional.

Client files- 5 client files were reviewed for health screenings, recent medical assessments, signed admission agreements, and IPPs. files are present and up to date. LPA noted the daily logs for the clients are very similar from client to client and day to day, LPA gave guidance the daily notes log, t22 is most interested in changes in condition away from baseline(physical/emotional/etc), and residents participation with activities/what the activities for that day (physical/group interaction/etc).

Staff files- 5 staff files were reviewed for health screenings, most recent training's, topics of original training, statements of qualification, and first aid/cpr. files are present and up to date. LPA gave guidance that annual staff training's are also opportunities to explore how to better serve the needs of the clients. If a client ends up with a restricted condition (wounds, tubes, injections, etc.), part of the care plan is that staff need 4 hours annual training related to that condition on top of the normal required topics and hours.

Administrator files- LPA reviewed the required postings, the facility license, the administrator certificate, the evacuation plan, and the infection control plan. The Administrator informed the LPA they were going to change the ownership structure from a sole proprietorship to a LLC, LPA asked for a LIC 200 with the updates to be sent to his email: noel.wolfpetersen@dss.ca.gov

P+I- 2 residents P+I were checked at random, one had a balance that was wrong but in the favor of the client by 10$, LPA gave guidance that the operator should self audit the records.

Client interviews- 5 clients were interviewed, all report no complaints about thier care.

Staff interviews- 1 staff was interviewed, able to describe the abuse reporting policy, personal rights of clients, and the way information is passed from one shift to the next.

no citations were issued, A copy of the report was read and left with the administrator. exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC809 (FAS) - (06/04)
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