500305863-3-25-2026-27-AS-NWPN-DSHREH-20260325125734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500305863
Report Date: 03/25/2026
Date Signed: 03/25/2026 12:57:51 PM

Document Has Been Signed on 03/25/2026 12:57 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:	GEORGIA'S GUEST HOME		FACILITY NUMBER:	500305863
ADMINISTRATOR/ DIRECTOR:	GEORGIA WILCOMB		FACILITY TYPE:	740
ADDRESS:	102 SOUTH G STREET		TELEPHONE:	(209) 529-7872
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY: 15		CENSUS: 9	DATE:	03/25/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Georgia Wilcomb		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct an annual inspection. LPA met with Administrator/licensee Georgia Wilcomb and explained the purpose of the visit. The Physical inspection included but was not limited to the bedrooms, bathrooms, kitchen, common areas, exterior, evacuation route. Facility is clean on the interior, traffic areas are unobstructed and well lit. Kitchen had adequate food storage and food for 15 people, at least 2 days perishable and 7 days non perishable food was observed. Kitchen had adequate lockable storage for sharps, toxics, and Medication. The Bathrooms had hardware in good repair, the water temperature was measured 105-120*F. The bedrooms had adequate furniture and furnishings, to include mattress encasements. Common areas and exteriors have adequate space for activities. Exterior has some upkeep needed, there is high grass in the back, trash in the form of 7/11 cups, fruits on the ground attracting flies. 5 client files were reviewed, to include health screenings, signed admission agreements, addendums to the admission agreement, needs and services plans, functional capability assessment. there were some changes to thier health. (for the better) where a different set of needs and services might apply to them. LPA gave guidance to the facility to get new 602 medical assessments and redo the needs and services plans for clients who have changes to their health. 5 staff files were reviewed, to include health screenings, finger printing clearance, first aid/cpr, and continuing/initial training. files are present and up to date. 4 clients were interviewed, 1 staff was interviewed. Continued on C page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: GEORGIA'S GUEST HOME	FACILITY NUMBER: 500305863
	VISIT DATE: 03/25/2026

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Administrator records were reviewed including but not limited to the control of the property(living trust), infection control plan, and required facility posters to include: facility sketch with evacuation routes, ombudsman/lpa contact information, personal rights, employee rights, and facility license with administrator certificate. files are present and up to date. LIC610d/e (evacuation emergency form)should be sent in to the LPA if theres any changes, if the idea is to use a temporary shelter location that does not have beds, the 610 should detail how bedding arragements will be made.

First aid kit has the requiried items, fire extinguisher is dated 2/14/26. there are no bodies of water on the property.

Facility is using cameras interior to the facility, the LPA is asking for a a waiver request letter to do cameras inside the facilitiy, public areas only, no bedrooms, no bathrooms, no audio recording. The licesnee should include a updated plan of operation where the camera policy is outlined, and an admission agreement ammendum notifying the residents they are recorded in the public areas of the facility, and a picture of a posted sign for the public notifying/warning them they would be video recorded on the property.

If the facility wanted to put up security cameras on the exterior of the facility, the LPA agrees that would be reasonable given the recent thefts, there should similarly be an update to the plan of operation that exterior facing cameras are in use at the facility.

No citations associated with this visit. A copy of the report was read and given to the administrator. exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC809 (FAS) - (06/04)

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