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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004748
Report Date: 08/17/2023
Date Signed: 08/29/2023 09:56:56 AM

Document Has Been Signed on 08/29/2023 09:56 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 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: 22DATE:
08/17/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Patricia LactaoenTIME COMPLETED:
01:30 PM
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Unannounced Plan of Correction visit was conducted on 08/17/2023 by Licensing Program Analyst (LPA) Charlie Yang to review and clear the deficiencies that were previously cited on 07/12/2023. This LPA was met by the facility house manager, Patricia Lactaoen, and a brief interview was conducted with her at this time. Current census was 22 residents of which most of them were out at their respectable day programs at this time. There were, however, (2) residents present at this time.
Brief tour of the facility food supply was conducted.

The following items were reviewed to make sure that they had been corrected and brought into compliance at this time:

(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.
This was not met by the facility as evidenced by the presence of expired food items within the food supply for the residents.

There were no deficiencies observed or cited at this time. All of the above deficiencies, with Plan of Correction, were reviewed and cleared at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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