507004748-4-28-2023-27-AS-LKIG-CSBLEU-20230530084206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004748
Report Date: 04/27/2023
Date Signed: 04/28/2023 09:50:18 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2023 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230202162811

FACILITY NAME:	EMPIRE GUEST HOME		FACILITY NUMBER:	507004748
ADMINISTRATOR:	JOAN LITTLE		FACILITY TYPE:	735
ADDRESS:	101 SOUTH G STREET		TELEPHONE:	(209) 522-1441
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY:	23	CENSUS: 21	DATE:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Mark Little		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are being neglected while in care
Staff failed to seek medical attention for residents in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Allegation 1. Residents are being neglected while in care, was found to be unsubstantiated based on record reviews and interviews with staff and residents. LPA interviewed staff S1, S2, S3. LPA also interviewed resident R1--R5. LPA also reviewed staff care notes and medical records for R1. Interviews conducted and records reviewed did not reveal a lack of care being performed. Based on interviews conducted and records reviewed the preponderance of evidenced standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation 2. Staff failed to seek medical attention for residents in a timely manner was found to be unsubstantiated based on interviews conducted with staff and resident in question (R1). Based on interviews conducted and records reviewed the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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