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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004748
Report Date: 06/18/2024
Date Signed: 06/18/2024 12:38:38 PM

Document Has Been Signed on 06/18/2024 12:38 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:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Joan Little, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 06/18/24, Licensing Program Analysts (LPA's) Renee Campbell arrived to the facility unannounced to conduct an annual inspection. LPA Campbell met with Joan Little, Administrator and explained the purpose of the visit. The facility is licensed to care for 7 non-ambulatory and 16 ambulatory clients ages 18 to 59 years of age. The administrator's certificate # 6010822735 will expire on 06/25/25. The current census is 22 residents with 11 staff. Of the 11 staff, all show as cleared for the facility per the Licensing Information System.

Upon entry, LPA Campbell observed the licensee, Doug Little, the licensee’s grandson, 1 resident watching TV , 1 staff cleaning the bedrooms and 1 staff person working in the dining room. The LPA and licensee conducted a walk through. The rest of the 22 residents were in day program. Bedrooms contained, chairs, closets, bureaus and lamps, nightstands, beds that had been made and chairs. There are 12 bedrooms and 4 bathrooms. There is a covered patio area outdoors containing, chairs, tables, and a soda machine. A pantry is outdoors as well containing enough food to last 7 days, a refrigerator for sodas and a chest freezer containing meat. A refrigerator in the kitchen contains enough perishable food for 3 days. The refrigerator temperature is set at 39 degrees Fahrenheit which is below required maximum temperature of 45 degrees F (7.2 degrees C). Two fire extinguishers were observed in the hallway of the facility and were last inspected on 11/29/23.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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: 06/18/2024
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The facility is a one floor dwelling with 12 bedrooms and 4 bathrooms. No body of water was found. LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility was observed to be free of odor and in good repair. The hot water temperature was measured in the resident bathroom at 110 degrees Fahrenheit which is within the required maximum range of 105 to 125 degrees Fahrenheit. There were no changes to the building layout since the most recent floor plan.

A washer and dryer was observed inside the facility. Any cleaning products were kept locked and inaccessible from residents in the laundry room. LPA Campbell observed that smoke alarms were functional and the emergency drill log. The last disaster drill conducted was a on 05/20/24/

Based on observation, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted and a copy of this report was given to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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