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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004748
Report Date: 07/12/2023
Date Signed: 07/16/2023 11:11:11 PM

Substantiated


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
05/18/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230518103031
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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joan LittleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff are providing expired food to clients.
INVESTIGATION FINDINGS:
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Unannounced complaint 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 co-Licensee, Mark Little, at this time.
Brief interview was conducted with the facility designated Administrator and co-Licensee.
Current census was 21 residents.
The purpose of this complaint visit was to deliver the findings of this investigation unto the facility and its representatives.
Based on a review of the facility food supply in the pantry room of this facility, this LPA looked over the expiration dates for the non perishable food items that were present on the shelves at this time.
It was observed that there were several boxes of non perishable food items that were expired and past the prime date that they could be used for meal preparations and consumption by the residents at this time.
This LPA requested that the present staff persons to remove these expired food items from the pantry area and dispose of them properly at this time.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20230518103031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
80076(a)(1)
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(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
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The facility designated Administrator stated that an audit of all facility food items will be conducted. All expired food items, perishable and nonperishable alike, will removed and disposed of accordingly. A statement of correction will be completed and submitted into CCL for review by this LPA
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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.
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by the due date of 07/13/2023.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/18/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230518103031

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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joan LittleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff speak to clients inappropriately

Facility staff yell at clients
INVESTIGATION FINDINGS:
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Unannounced complaint 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 co-Licensee, Mark Little, at this time. Brief interview was conducted with the facility designated Administrator and co-Licensee.
Current census was 21 residents.
The purpose of this complaint visit was to deliver the findings of this investigation unto the facility and its representatives.
Based on interviews and a review of the forms and documents obtained during this investigation, it was learned that most of the residents have been living here at this facility for quite some time. Some residents were recently placed within the last 6 months to a year but the majority have been residing here for longer than 5-10 years, on average, at this facility.
It was learned that the care needs varied from one resident to another but the facility personnel were properly trained and deemed competent to deal with, and meet, the everyday needs of the residents in care.
It was learned that facility personnel were compassionate about the level of care that they provided unto the
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230518103031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
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residents in care.
Based on interviews, it was learned that facility personnel were deemed to be respectful towards the residents in care and also spoke to them accordingly. It was learned that facility residents felt that they were safe within the confines of this facility and felt that they could approach the facility personnel for assistance without fear of retaliation or retribution.
It was learned that there were days when the facility personnel and facility residents just did not see eye to eye and disagreements were bound to take place. Yet, based on interviews it was learned that the facility personnel still treated facility residents with respect and spoke to them in a well mannered tone.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited during today's complaint visit at this time.

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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230518103031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
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As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeals rights were printed and a copy was given to the facility designated Administrator Joan Little at this time.

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
LIC9099 (FAS) - (06/04)
Page: 5 of 5