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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500305863
Report Date: 12/12/2024
Date Signed: 12/12/2024 02:44:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240808070850
FACILITY NAME:GEORGIA'S GUEST HOMEFACILITY NUMBER:
500305863
ADMINISTRATOR:GEORGIA WILCOMBFACILITY TYPE:
740
ADDRESS:102 SOUTH G STREETTELEPHONE:
(209) 529-7872
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:15CENSUS: 11DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Georgia Wilcomb, LicenseeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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4
5
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8
9
Facility staff not following infection control practices
Facility staff not properly cleaning dishes
INVESTIGATION FINDINGS:
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2
3
4
5
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7
8
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10
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13
On 12/12/2024, Licensing Program Analyst Renee Campbell arrived to the facility to deliver findings regarding a complaint. LPA Campbell was met by Georgia Wilcomb, Licensee and explained the purpose of the visit.

Regarding the allegation that facility did not follow infection control practices, based on intervew with C1, staff did not wear masks during a COVID outbreak in the facility.
Regarding the allegation that staff did not properly clean dishes, based on interview with S1 and C4, because C4 liked to "stay busy" by doing dishes, C4 would do the dishes directly after dinner. However, S1 stated that because C4 did not clean them well enough, staff had to do the dishes again after C4 washed them.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240808070850

FACILITY NAME:GEORGIA'S GUEST HOMEFACILITY NUMBER:
500305863
ADMINISTRATOR:GEORGIA WILCOMBFACILITY TYPE:
740
ADDRESS:102 SOUTH G STREETTELEPHONE:
(209) 529-7872
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:15CENSUS: 11DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Georgia Wilcomb, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not maintaining facility in a clean condition
Facility staff not maintaining facility in an odorless condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/12/2024, Licensing Program Analyst Renee Campbell arrived to the facility to deliver findings regarding a complaint. LPA Campbell was met by Paul Hardin, Administrator and Georgia Wilcomb, Licensee and explained the purpose of the visit.

Regarding the allegation that staff are not maintaining the facility in a clean and odorless condition, LPA Campbell observed no odors in the facility and upon entry, noted that chairs were on top of the tables to facilitate mopping and sweeping in the dining room. Client C1 also stated that staff occassionally swept and mopped client rooms when allowed.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited.  Exit interview was held and a copy of report was given to Georgia Wilcomb
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240808070850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GEORGIA'S GUEST HOME
FACILITY NUMBER: 500305863
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2024
Section Cited
CCR
87470(b)(2)
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All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents.... This requirement is not met as evidenced by:
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5
6
7
Licensee will read regulation 87470(b)(2), review and/or update the facility infection control plan as neede and submit a signed declaration of understanding to LPA by POC due date. Declaration to include understanding of mask requirement and signed by all staff.
8
9
10
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13
14
Based on interview, staff were not wearing a mask or gloves while in the presence of residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
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9
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14
Type B
12/20/2024
Section Cited
CCR
87468(a)(2)
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7
Personal Rights of Residents in all facilities. (a)Residents in all residential care facilities for the elderly shall have all other following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations. This requirement is not met as evidenced by:
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Licensee will read regulation 87468(a)(2) and submit a signed declaration of understanding to LPA by POC due date and present a plan to redirect clients in regards to dishwashing by POC due date.
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14
Based on interviews, a client was allowed to wash dishes inadequately to the extent that staff had to wash dishes again to clean them.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4