<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004748
Report Date: 07/12/2023
Date Signed: 07/21/2023 12:02:06 PM

Document Has Been Signed on 07/21/2023 12:02 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 AC/SC, 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: 21DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joan LittleTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Unannounced annual visit made out to this facility on 07/12/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Joan Little and Mark Little. Brief interview was conducted with the facility designated Administrator Joan Little and co-Licensee Mark Little at this time.
It was learned that this facility was licensed for a total of 23 residents, of which, (7) were allowed to be non-ambulatory.
This facility was also vendorized through Valley Mountain Regional Center as well.
Current census was 21 residents, of which, (2) residents were present at this time while the other residents were out of this facility at their respectable day programs. It was also learned that (6) residents were away at a summer camp for the week as well.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed for an adequate supply of plates, silverware, and other items intended for use by the residents. Cleaning agents and detergents were stored and maintained under the sink cabinet which was observed to be locked and made inaccessible to the residents at this time.
Knife drawer was observed to be locked and made inaccessible to the residents at this time.
Food supply was reviewed for an adequate supply of 2-day perishable and 7-day nonperishable food quantities at all times. LPAs observed several food storage units within this facility in the form of additional refrigerator and freezer units.
Medication room was toured. LPAs observed the use of a medication cabinet that was locked and made inaccessible to the residents at all times.
This facility employed the use of an paper MAR system to dispense, manage, and document all medications for the residents at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 12/12/2022 by the local fire extinguisher company, USA Stanislaus Company, and in compliance at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EMPIRE GUEST HOME
FACILITY NUMBER: 507004748
VISIT DATE: 07/12/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms (4) was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the common areas was conducted. Living area, dining area, and all other areas designated for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the exterior grounds was conducted. Storage sheds were observed to be present and in use at this time. It was learned that client belongings were inventoried and stored in bins in one of the sheds.
Cleaning supplies and items used to repair and upkeep this facility were also stored in another shed unit as well. All of the shed units were observed to be locked and made inaccessible to the residents at this time.
Facility perimeter fence, side gates, and all exits were reviewed.

The following forms and documents were requested by this LPA to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

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

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2