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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004748
Report Date: 05/14/2024
Date Signed: 05/14/2024 03:19:46 PM

Document Has Been Signed on 05/14/2024 03:19 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:
05/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Joan Little, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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LPA Campbell visited the facility for the first time on 05/14/24 at approximately 12:30 pm to clarify two incident reports written on 05/10/24 about a blood transfusion performed for a resident.

Incident reports were written regarding R1. R1 is a diabetic and has difficulty being understood due to their throat being injured as a child. LPA Campbell reviewed R1's 602 and discharge paperwork

R1 had fallen twice at the facility and on 05/10/24 R1 fell at the day program. At that time, the day program staff had R1 see his primary doctor at the Central Valley Pace Day Program and Health Clinic for a health examination. PACE called the facility to report the fall while R1 was examined on 05/10/24 by his primary physician who also works on the premises. After R1 left PACE, discharge paperwork was provided to the facility.

PACE then referred him to Doctor’s Medical hospital for further examination. After leaving Doctor’s Medical on 05/10/24, R1 received a prescription for a multivitamin. That same day, Dr. David Dunitz with PACE reviewed R1’s medical records with Doctor’s Medical and then requested that David return to Doctor’s Medical hospital for further observation and for a blood transfusion. R1 remained at the hospital from 05/10/24 to 05/14/24 and will be returning this date on 05/14/24.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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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: 05/14/2024
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The facility notified R1’s closest family member as noted on the incident report. The family member gave permission for R1’s blood transfusion because R1 has difficulty being understood due to their throat injury.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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