Georgia's Guest Home

Allegation investigated: Staff do not provide adequate supervision to the residents in care. Resident eloped from facility.

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a complaint investigation into the above allegations, LPA met with the administrator Georgia Wilcomb and explained the purpose of the visit. LPA attempted to interview 8 neighbors, 3 responded that no person was discovered wandering thier property, 2 declined to interview, 3 were unavailible. The LPA contacted the county sheriffs office, no missing persons reports were filed for residents of the facility in the period of March to May 2026. The facility has a sign out log for residents, most residents participate with the logs. Administrator Identified one client who has approached neighbors houses in the past, unclear if that client was involved. 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, therefore the allegation are unsubstantiated.no citations issued with this visit. A copy of the report was read and given to the licensee, exit interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 19, 2026 · control 27-AS-20260526090222

Allegation investigated: Facility is unkempt.

~ LPA arrived to the facility to open the complaint investigation into the above allegation. LPA met with the administrator Georgia Wilcomb to explain the purpose of the visit. A previous report by the LPA outlined some areas for improvement with the cleanliness of the facility. ~ LPA made a walk through of the property for an observation, the inside is clean. there are some matresses and a lawn mower out on the lawn/gargen area. The soda trash is significantly reduced from last time in the food storage area, just 1 mostly empty cup. Lemon tree side still has 5+ pepsi cans, 5+ rotting ground fruits, 15+ cigarrete butts under the eaves. There are some ash trays out there with some limited use, LPA gave guidance to police the butts and get more buy in from the residents about using the ash trays, there is a dry grass around and its may. Many of the residents have some limitation on thier mobility, it would not be unreasonable to have 1 ashtray accessible to each outdoor seat. Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.) ~ Citation issued, a copy of the report was read and given to the administrator. Appeal rights provided, exit interview was conducted. Substantiatedthe state’s words, verbatim · CDSS document, May 27, 2026 · control 27-AS-20260526090222

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 3, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: some trash on the back porch, its pepsi cans, ciggarette butts, rotting fruit along with some items that should be put away, mattresses/a lawnmower. not following this requirement presents a risk to the clients health, saftey, or personal rights.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Send a picture to the LPA when the area is cleaned up, by 6/3/26. either the LPA's phone 6193234509 or the email noel.wolfpetersen@dss.ca.gov

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Mar 25, 2026

Allegation investigated: Staff does not ensure resident is taking prescribed medications. Staff does not ensure resident's medication is refilled in a timely manner. Staff does not ensure resident's medical needs are being met. Staff are abusing residents in care.

On 09/04/2025, Licensing Program Analyst (LPA) Renee Campbell arrived at the community to complete an investigation and present findings. LPA Campbell met with Georgia Wilcomb, Licensee and explained the purpose of the visit. Upon entry, LPA Campbell observed the licensee speaking with residents and working in the kitchen cleaning. Regarding the allegation thats staff does not ensure resident is taking prescribed medications and that staff does not ensure resident's medication is refilled in a timely manner, LPA Campbell interveiwed R1 and R2. Both residents reported that when staff offer medications, they take it and neither R1 or R2 refuse the medications. LPA Campbell reviewed the Medication Administration Record (MAR) and found no refusal of medications recorded. Of the 11 residents present in the facility, R1 is the only resident whose medication is not refilled automatically. The licensee and F1 confirmed during separate interviews that F2 had been unable to pick up a refill on time. Unsubstantiated Regarding the allegation that staff does not ensure residents medical needs are being met, the facility has a doctor that makes house calls who can also be called for assessments as needed. The licensee has taken R1 to the eye doctor and R3 to the cardiologist. LPA Campbell observed the facility appointment calendar that is used to track medical appointments and visits for the community. R4 stated that they had been taken to have a mammogram and for lab work. When LPA Campbell spoke with F1 regarding a residents need for blood pressure, it was confirmed that the resident had no doctors orders on file and that the resident no longer needed their blood pressure taken. Regarding the allegation that staff are abusing residents in care, LPA Campbell spoke with R1, R2 and R3. None of the residents interviewed mentioned verbal or physical abuse and stated that staff treated them well. 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, Chapter 8,no deficiencies cited. Exit interview was held and a copy of report was given to Georgia Wilcomb, Licensee.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 27-AS-20250605110837

Allegation investigated: Staff do not ensure residents are provided clean clothing to wear while in care Staff engages in inappropriate conversations with other adults while in the presence of residents in care Staff do not ensure resident are provided snacks in between meals Staff do not arrange transportation for residents medical appointments

On 07/08/2025, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to open a complaint investigation. LPA Campbell met with Licensee Georgia Wilcomb and explained the purpose of the visit. Regarding the allegation that staff do not ensure residents are provided clean clothing to wear while in care, upon entry to the community, LPA Campbell observed Licensee Wilcomb doing laundry in the laundry room. When interviewed, R1, R2 and R3 reported that staff do their laundry and that staff do not want them in the laundry room. LPA Campbell observed residents wearing clothes in good repair, without stains and observed no odors in bedrooms. Regarding the allegation that staff engages in inappropriate conversation with other adults while in the presence of residents in care, none of the residents interviewed stated witnessing or hearing about staff discussing inappropriate topics. R2 stated “I don’t even hear them talking about each other and that’s rare with staff”. Unsubstantiated Regarding the allegation that staff do not ensure residents are provided snacks between meals, R1, R2 and R3 were asked if they have access to snacks. Residents interviewed stated they felt free to take snacks from the kitchen when they were hungry. This abides by regulation 87464 (f)(3) which states that three snacks be “made available daily” to residents in care of the community. LPA Campbell also observed an abundance of foods in an outside cabinet and refrigerator that were accessible to residents. LPA Campbell observed a resident go outside and grab food from a refrigerator. Regarding the allegation that staff do not arrange transportation for residents medical appointments, R1, R2 and R3 all reported that staff will arrange transportation with Lyft, Dial a Ride or arrange it through their insurance provider. They reported no issues getting to their appointments. There are also six residents who receive medical care through their primary physician who conducts home visits in the community. Per the residents interviewed and their Medication Administration Record (MAR) Unless requested otherwise, the community orders medication refills and disperse the medication as directed by their doctors. 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.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 27-AS-20250701085336

Type of visit: Case Management - Other

On 07/08/2025, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced regarding a phone call made on 07/07/2025 by Licensee, Georgia Wilcomb. LPA Campbell met with Licensee Georgia Wilcomb and explained the purpose of the visit. On 07/07/2025, the Licensee, Georgia Wilcomb, called LPA Campbell and reported that R1 had moved out as of 07/03/2025. On 07/02/202, R1 continually exhibited behaviors involving R1 screaming at R2 directly in his face. Per R2 and the Licensee, R1 had been shouting in people's faces during other incidents for some time but there were no physical altercations. When R1 took a shower after the 07/02/2025 incident and after the Licensee brought him clothes, the Licensee called R1’s Case Worker (C1). While the Licensee was on the phone with C1, R1 began to shout and scream at the Licensee. Upon hearing this, C1 stated they would come out to the community on 07/02/2025 Because R1 had a Telecare Appointment, C1 spoke to R1 until R1 had calmed down and took R1 to his appointment. R1 then moved to a new community on 07/03/2025 as R1 requested. LPA Campbell spoke with C1 who confirmed that R1 had been wanting to move to a different community for some time. Once a room was available with a friend of R1's, C1 assisted R1 with moving on 07/03/2025. When contacted, C1 reported that R1 was satisfied with his placement. Based on today's visit, per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited. A copy of this report with left with Georgia Wilcomb, Licenseethe state’s words, verbatim · CDSS document, Jul 8, 2025

Type of visit: Case Management - Deficiencies

On 6/11/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) arrived unannounced at the facility to conduct a case management visit. The LPA and LPM met with Licensee Georgia Wilcomb and explained the purpose of the visit. The LPA and LPM conducted a tour of the facility. While touring the facility, the LPA and LPM observed a spray bottle of bleach cleaner on a wooden hutch located in the dining room. The bleach bottle was accessible to the residents in care, presenting a risk to health and safety. As a result of this case management visit, one deficiency was cited (see LIC809-D). The facility is not in compliance with Title 22 Regulation. An exit interview was conducted with Licensee and a copy of the LIC 809, LIC 809-D, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(1) · Plan of correction due date: Jun 11, 2025

87309 Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions...which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation and interview, Licensee did not comply with the section cited above, as staff left a bottle of bleach on a wooden hutch in the dining room, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee removed the bottle of bleach from the hutch and put it in locked storage.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell and arrived at the facility to conduct an unannounced annual inspection on 02/19/2025. LPA met with Georgia Wilcomb, Administrator and Licensee and explained the purpose of the visit. 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. This facility is a single story building licensed to serve fifteen (15) non-ambulatory and ambulatory residents. Upon entry, LPA Campbell observed food on the floor and a dining table that was still sticky from the morning breakfast. The facility was free of odor. LPA Campbell observed staff take out the garbage, but when opened a few minutes later, garbage had been placed in the garbage can without a liner. Spider webs were observed on light fixtures and painters tape was still on other ceiling light fixtures. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. Of the four bathrooms, three were observed with clothing or towels on the bathroom floor and showers had not been cleaned. Administrator Willcomb stated the bathrooms had flooded yesterday and impacted the floors..Assistance with the toilet flooding was received from neighbors and equipment per the administrator was used that the facility kept on site. There are currently no bodies of water present. LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers were last inspected on March 25, 2025. The smoke and carbon monoxide detectors were tested and found to be in good repair. Facility thermostat was observed at 76 degrees Fahrenheit. LPA Campbell checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit contained scissors, thermometer and tweezers. The first aid manual could not be found per the administrator. LPA Campbell requested 4 of 11 client files and 4 of 5 staff files for review. Staff files were disorganized, missing pages or did not have the folder needed to retain paperwork. The administrator had to spent more than 5 minutes finding the requested information for staff. Three of four files were not complete. Though the administrator could not find their most current Administrator Certificate, online records show that it is active. Client file organization had improved since prior visits. Toxins were made inaccessible to clients in care. Toxins are stored in the laundry room with the files. The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 02/27/2025 by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil penalties.the state’s words, verbatim · CDSS document, Feb 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(1) · Plan of correction due date: Feb 28, 2025

87411 (c)(1) Staff providing care shall receive appropriate training in first aid. This requirement was not met as evidenced by: Based on file reviews, 2 of 4 files reviewed did not have documentation of 1st aid certification.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: The administrator will audit all staff files for first aid documentation, have staff complete 1st aid renewal training where needed and add 1st aid cards to staff files. The administrator will send

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Apr 28, 2025

The licensee shall ensure that personnel records are maintained... Each personnel record shall contain the following information: (7) Past experience ...employers.(11) A health screening Based on file review, 1 of 4 files did not contain a health screening and 1 of 4 files did not have a job application or personnel record.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: The administrator will participate in a Technical Support Program. The licensee will maike every effort to work with the TSP analyst at the facility. The POC will not be cleared until participation with TSP is complete and until the TSP analyst has made 1 or more visits to the facility as needed.

Allegation investigated: Facility staff not following admissions agreement Facility staff not ensuring residents have access to hygiene items

On 01/02/2024, 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. In regards to the allegation that staff are not following admissions agreements to arrange transportation for medical visits, C4 and C1 reported that staff arrange transportation or the doctor comes to the home for medical examinations. C2 reported that her daughter comes to take her to the doctor. When asked, the clients interviewed stated they had not been taken to doctor’s appointment via ambulance. In regards to the allegation that staff are not ensuring residents have access to hygiene items, C4 reported that she never knew where the soap or tissue came from, since "they just always had it." C1 also stated that “They provide soap and tissue. This is a real nice place.” And C3 confirmed this. LPA Campbell also observed that incontinence pads were stored in a storage shed in the carport. Unsubstantiated 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 Wilcombthe state’s words, verbatim · CDSS document, Jan 2, 2025 · control 27-AS-20240808070850

Allegation investigated: Facility staff not following infection control practices Facility staff not properly cleaning dishes

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. Substantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 27-AS-20240808070850

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2) · Plan of correction due date: Dec 20, 2024

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: 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.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(2) · Plan of correction due date: Dec 20, 2024

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: Based on interviews, a client was allowed to wash dishes inadequately to the extent that staff had to wash dishes again to clean them.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: 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.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

On 11/13/24, Licensing Program Analyst Renee Campbell conducted a Case Management visit for R1 who was experiencing a possible medical incident. LPA Campbell met with Licensee Georgia Wilcomb and explained the purpose of the visit. During visit, R1 reported she wasn’t feeling well to Georgia Wilcomb, Licensee. R1 was overheard stating she was worried about the bright blood in her stools but did not want to go to the doctor. Later, a shout of pain was heard from her direction. Licensee Georgia Wilcomb investigated and reported to LPA Campbell that R1 was experiencing abdominal pain and still did not want to go to the doctor. The licensee stated that R1’s primary doctor suggested she go to the emergency room but R1 refused. After speaking with R1, they continued to refused medical intervention. LPA Campbell then suggested that the licensee call 911 for assessment. LPA Campbell observed emergency personnel arriving within 5 minutes at approximately 1:54 pm. Once they arrived, R1 refused to let them assess. Emergency personnel then left after reporting that R1 refused to go to the emergency room or submit to assessment. No documentation was provided to the facility or R1. LPA Campbell suggested that Licensee Wilcomb check on R1 and log her status to ensure she is alert and oriented. LPA Campbell reviewed the LIC 602 for R1. Their Primary Diagnosis is listed as Syncope and Collapse and their Secondary Diagnoses was Hyperlipidemia. R1 is ambulatory, able to leave the facility alone and experiences depression. The licensee was advised to continue checking on R1 to ensure they are alert and oriented An exit interview was held and a copy of this report was left with facility staff. .the state’s words, verbatim · CDSS document, Nov 13, 2024

Type of visit: Case Management - Deficiencies

On 08/13/24, Licensing Program Analyst (LPA) Campbell arrived to the facility unannounced and met with Georgia Wilcomb. LPA Campbell observed a car parked in the driveway and a resident standing outside. Due to the presence of residents with COVID, LPA Campbell did not enter the facility. Despite several requests from the Department during Non-Compliance Conference and Case Management meetings on 08/17/23, 9/15/23 and 3/24/24 to provide proof of a qualified active administrator for 20 hours per week, the licensee did not request renewal until a week before her administrator certification expiration date when the request arrived in the Administrator Certification Section on 04/03/24. Presently, there is no qualified administrator associated to the facility. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Aug 14, 2024

87405 Administrator Qualifications and Duties All facilities shall have a qualified and currently certified administrator. This requirement is not met based as evidenced by Based on record reviews, there is not a qualified and certified administrator present at the facility. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2024

Plan of correction: The licensee will review the regulation cited and write a statement of understanding of the regulation cited. Statement will be emailed to LPA Campbell by POC date 08/14/2024 by POC date. The licensee has submitted their Administrative Certification renewal.

Type of visit: Case Management - Legal/Non-compliance

On 07/29/24, Licensing Program Analyst (LPA)and LPA Avelina Martinez arrived unannounced to verify the facility has completed the requirements as discussed during an NCC Conference on 03/15/24. Upon entry, LPA Campbell observed a kitchen table with food and oils that needed to be cleaned before use. LPA Campbell conducted a tour of the facility and observed that the floors had been replaced throughout the dining room and hallways. A camera was observed in the living room. Licensee Georgia Wilcomb reported that they did not work. Images were taken of pests on the floor near the kitchen. No smoke alarm was observed in one of the bedrooms. Another bedroom still had painters’ tape around the sprinklers and lights. Chemicals, power tools, paint and debris from a recent paint job were observed in the dining room, patio and in the front of the facility. The fire extinguishers were on the floor and not braced on the wall. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights are provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 30, 2024

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requiremet is not met as evidenced by: Based on observation, no smoke alarm was found in a client's bedroom which poses an immediate health, safety or personal rights riks to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2024

Plan of correction: During visit, maintenance staff hung up the smoke detector.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Aug 9, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. ... for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, roaches were observed on the floor, chemicals, debris and powertools were observe as accessible to clients and fire extinguishers were on the floor instead of being braced on the wall.the state’s words, verbatim · CDSS document, Jul 29, 2024

Plan of correction: Facility will create a plan to maintain a clean, safe and sanitary facility in good repair at all times after completing work at the end of the day.

Type of visit: Case Management - Other

On 06/13/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to complete a case management begun on 05/23/24. LPA Campbell entered the premises to confirm if any updates to the torn rugs had been made and if staff files were complete. Upon arrival at approximately 8:35 am, LPA Campbell observed residents in their beds asleep. The rug had not been changed and still had tears. No awake staff were observed in the dining, living room or any common areas. A resident (R1) was observed sleeping in the chair in the living room. LPA Campbell asked where staff was and the resident stated, “Linda should be around somewhere.” LPA Campbell again walked around the facility and looked in the backyard and observed no staff. LPA Campbell walked out to the driveway of the facility to contact LPA Arielle Pascua who was consulted by phone regarding the lack of staff. Administrator and Licensee Georgia Wilcomb was then called at approximately 8:49 am and notified of the lack of staff and stated they were “Just around the corner” and would be there. LPA Campbell returned inside of the facility to await the administrator. Within a few minutes, staff member Linda Cavin walked into the facility and stated, “I had to go get my glasses so I could do the medication.” When Administrator Wilcomb was informed of why there was no staff, they stated, “Well she only lives 50 feet away.” As a result of this case management, citations are issued under Title 22, Division 6. A civil penalty in the amount of $500 was issued. Due to time constraints and additional deficiencies, the Department will return to this facility to complete this case management visit. An exit interview was conducted with Georgia Wilcomb and a copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Jun 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1568.0822(c)(3) · Plan of correction due date: Jun 17, 2024

1568.0822 (c)(3) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation... 3. Absence of supervision, as required by statute and regulation. This requirement is not met as evidenced by: Based on observation, the licensee did not ensure alert and awake staff were present in the facility which poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: The licensee will write of statement of understanding that alert, awake staff are to be present in the facility continuously at all times. All staff will also sign a statement that they understand that they are not to leave the facility when on their shift at any time unless there is an emergency disaster requiring the evacuation of all residents or all residents are on an outing.. The documents are then to be provided to LPA Campbell via fax or email at renee.campbell@dss.ca.gov

Type of visit: Case Management - Other

LPA Campbell arrived to the facility on 05/23/24 unannounced to follow up on prior plans of correction. LPA Campbell drove to the facility and was met by the administrator, Georgia Wilcomb, outside of the building. Upon entering the facility, LPA Campbell observed residents sitting on the patio and eating in the dining room. A podiatrist was present providing service to the residents one at a time. LPA Campbell explained the purpose of the visit to the administer to verify completion of the plan of correction (POC) from the April 05, 2024 deficiency from the Legal Compliance meeting. According the the POC, the facility was to make significant progress in the kitchen, bathroom, and for rugs/flooring. As of 05/23/24, No progress had been made for the rugs in the hallways and living areas. Two areas of the rug are still taped down with duct tape and still provide a tripping hazard. Staff files were also reviewed. When asked, Administrator Wilcomb stated there were only three staff working in the facility. Per Administrator Wilcomb, no volunteers are working. LPA Campbell conducted an LIC859 Staff Records Review for the three staff files. They included Steve Hardin, Administrator Wilcomb and Linda Cavin. Though the administrator mailed the requested documents to the regional office, employee files lacked CPR certification, employee rights and/or ongoing training certificates at the time of review. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. Due to time constraints, the Department will return to this facility to complete this case management visit. An exit interview was held with Georgia Wilcomb, Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g) · Plan of correction due date: May 31, 2024

Personnel Records 87412(g) (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by: Based on record review, none of the requested documents were present in the facility as required. This poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: Administrator will ensure that all required documents will be in individual files for each staff and resident and ready to review by 05/31/24.

Type of visit: Case Management - Other

On 05/01/24, Licensing Program Analyst Renee Campbell arrived to the facility unannounced and met with Administrator Georgia Wilcomb to conduct a case management. LPA Campbell reported to Administrator Wilcomb the purpose of the visit. The purpose of the visit is to follow up on substantiated allegation from 04/11/24 under complaint 27-AS-20240125090756. On 04/11/24, LPA Avelina Martinez substantiated allegations that unlicensed care was being provided at 32 South G St, and required the licensee to move R1 to this facility where they could obtain a higher level of care. LPA Campbell requested the file for R1 and Administrator Wilcomb provided the following documents: Preplacement Appraisal Client Personal Property and Valuables (with clothes listed) Appraisal/Needs and Services Plan Personal Rights form (signed) Identification and Emergency Information Consent for Medical Treatment Admission Agreement form (signed) Per the administrator, the 602 will be completed by the facility physician, Dr. Josh Kemei by 05/10/24 at the latest. If the physician fails to abide by this appointment, the administrator will call to make an office appointment between the doctor and R1 for a face to face meeting with R1 and report the new date to LPA Campbell. A copy of this report was left with the facility.the state’s words, verbatim · CDSS document, May 1, 2024

Type of visit: Case Management - Other

On 04-11-2024 at 8:45 AM, Licensing Program Analysts (LPAs) Avelina Martinez and Renee Campbell conducted an unannounced visit to conduct a case management. LPA Avelina Martinez and LPA Renee Campbell met with Georgia Wilcomb and explained the purpose of today's visit. The purpose of this visit is follow up on learned deficiencies during a complaint investigation 27-AS-20240125090756. On April 04, 2024, LPA Martinez conducted an unannounced complaint visit. During April 04, 2024 complaint visit, LPA Martinez witnessed no care staff at approximately 8:30 AM. It was learned the assigned volunteer care staff left the facility for unknown time frame. LPA Martinez called the Licensee upon arrival at facility, and resident 1 (R1) called volunteer staff 1 (VS1). VS1 arrived at the facility at approximately 9:00 AM. VS1 left the facility to complete personal errands. As a result, the facility will be cited for not providing care and supervision to residents in care. An civil penalty shall be assessed on April 11, 2024 in the amount of $ 500.00 for the immediate health and safety risk of leaving residents alone. Additionally, LPA Martinez was informed R1 assists resident 2 (R2) with showers. Georgia Welcomb was informed only care staff should be providing care and supervision to residents in care. Furthermore, Georgia was advised R1 is not able to oversee the facility and residents in care due to the fact that R1 is a resident. LPA Martinez also reviewed the September 09, 2023 Non-Compliance Conference compliance (NCC) agreement and concerns. Due to recent care and supervision deficiency, the facility has not complied with NCC compliance agreement. The continued concerns are the following: Facility staffing Oversight of facility staff for proper care and supervision Due to immediate health and safety concerns and history of non-compliance with staffing regulations, LPA Martinez requested weekly work schedules be emailed every Monday at 8:00 starting April 15, 2024 until additional staffing has been hired. Staffing Plan: Licensee reported they are present at the facility 40 hours per week. The Licensee has finger printed/background clearance 4 potential employees. Licensee will add VS1 on payroll, and have a set schedule. LPA Martinez will continue to follow up with Georgia regarding staffing concerns. As a result, of this case management, deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of this report, 809-D page, and appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Apr 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(4) · Plan of correction due date: Apr 11, 2024

87468.2(4) Additional Personal Rights of Residents in Privately Operated Facilities...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs... This requirement was not met as evidence by: Based on observation and interviews on 04/04/2024 care staff 1 left the facility and left residents alone for unknown time period. When LPA Martinez arrived at the facility there were no care staff. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Licensee has implemented staffing plan. Licensee will email weekly staffing schedule to LPA Martinez by POC date 04/11/2024. Licensee provided staffing schedule to LPA Martinez during this visit. Licensee will email weekly staffing schedules until additional staff has been hired.

Type of visit: Case Management - Legal/Non-compliance

On 04/11/24, Licensing Program Analyst (LPA) Renee Campbell and LPA Avelina Martinez arrived to the facility to review the requirements as agreed to in the prior Noncompliance Conference on 03/25/2024. As discussed at the NCC Conference, licensee has agreed to provide corrections for the following issues by the following dates: 1. Licensee will provide copies of Linda Cabin's trainings by 4/12/24. Per Licensee, Georgia Wilcomb, staff will need a month to complete their training and licensee will provide proof of payment and vendor's name by 04/18/24. 2. Licensee will provide proof of administrator renewal resubmitted, and proof that they have paid for renewal of the administrator certificate in the form of a receipt and/or a copy of a cleared check by 04/05/2024. Currently, proof of the cleared check is pending. LPA Campbell will verify if a copy of the administrator renewal application has arrived via certified mail once back in the office. 3. Verify that everyone in the unlicensed facility has been assessed within 15 days after the NOVL was issued on 03/25/24. Per the licensee, the one resident who was in need of Care and Supervision has been moved to the licensed facility next door as of 04/05/24 and was observed in the facility by LPA Avelina Martinez on 04/11/24. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's visit. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 11, 2024

Type of visit: Case Management - Other

On 03/29/24, at approximately 9 am, Licensing Program Analyst (LPA) Renee Campbell arrived to facility to go over the last NCC meeting reports and obtain signatures. LPA Campbell met with Licensee Georgia Wilcomb and explained the purpose of the visit. Upon entry of the facility, LPA Campbell observed one resident sitting in a wheelchair under a carport. Another resident was observed eating cereal in the dining room with the lights off until another resident came and turned them on. Clients either watched TV in the common living room or remained in their rooms. LPA Campbell reviewed the NCC Meeting notes with the licensee and during the discussion, Licensee Wilcomb confirmed that Code Enforcement had been unable to access the Unlicensed Facility during a prior vist and that she planned to call to schedule an appointment with them to come on 04/05/24 when they could return. The licensee suggested several ways that she could continue to help residents living in the unlicensed facility by providing frozen meals, helping them get them get food stamps or providing a physician for health screenings. Licensee also stated that the same residents were independent. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 29, 2024

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted on this day, 03/25/2024, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after the Non-Compliance Conference was last held on 09/15/2024. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Renee Campbell, Teresa Alvarez, Patient Rights, Melissa Flaherty, LTC Ombudsman Coordinator and Licensee/Administrator Georgia Wilcomb. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well. The focus of the concerns at this time were as followed: Status of building and ground improvements. Use of 911 as a non-emergency method of transportation to medical care and to replace staff instead of lifting uninjured residents off the floor. Documentation of Administrator renewal Clients in need of a higher level of care in an unlicensed facility, on neighboring property. Training and clearance for all staff Licensee agreed to do the following in order to bring the facility into compliance. Update on facility building improvements. No longer use 911 for non-emergencies and provide transportation to doctor’s appointments as needed. Send documentation of administrator renewal via certified mail to include: proof of classes and units taken, receipts for fees paid. Copies of training and clearance for all staff. Needs and assessment plans for neighboring room and board, including allowing licensing to inspect and determine residents don’t need care and supervision. Exit Meeting. Licensee / Administrator signature on file.the state’s words, verbatim · CDSS document, Mar 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87404(d)(2) · Plan of correction due date: Apr 5, 2024

87404 Administrator – Qualifications and Duties (d)(2) The administrator shall have ... Knowledge of and ability to conform to the ...regulations. This requirement was not met as evidenced by Based on LPA Martinez’s interview , R1 stated he needs help with his activities for daily living. R1 needs a higher level of care than he is receiving at licensee’s unlicensed facility. Which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: The Administrator will require all future residents of the unlicensed facility to provide a physicians report that confirms a resident requires no assistance with medication or acivities of daily living by POC date. R1 will be moved to the licensed facility next door immediately by 4/05/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(2) · Plan of correction due date: Apr 30, 2024

87307 (d)(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on observation, interviews and record reviews, the licensee has not begun improvements to ensure facility is clean safe, sanitary and in good repair. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Administrator states that by the next NCC meeting, significant process will have been made in the kitchen, bathroom, and for rugs/flooring.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69 · Plan of correction due date: Apr 30, 2024

Employees assisting...with...medi- cation; training requirements (B) Two years...experience,.. as an administrator ...during which time the individual has acted in compliance with applicable regulations. This requirement was not met as evidenced by: Based on observa- tion, interviews and record review ,the licensee provided training to an employee while not in substan- tial compliance with applicable regulations.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Licensee will utilize training from vendor to mainting medication training requirements. Licensee wll provide a training plain with vendor names and class topics by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1533 · Plan of correction due date: Apr 19, 2024

Section 1533 ..any authorized ... employee,... State Department of Social Services may, enter ...any place providing ..care and .. services .. to prevent a violation of, any provision of this chapter. This requirement was not met as evidenced by: Based on obser- vation, licensee did not ensure the unlicensed facility was accessible to authorized employees of the State Dept of Social Services.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Licensee will replace the lock and obtain a new key for the unlicensed facility and be available within the hour to allow access by POC date.

Type of visit: Case Management - Other

On 02/16/24, LPA Renee Campbell arrived to the facility to conduct a case management regarding areas of concern discussed during a Non-Compliance Conference conducted on 09/15/2023. The facility was to complete the following tasks and have the following items present on the premises. · Complete and Submit the LIC 500 for the most current staff, shifts, and coverage · Complete and Submit the LIC 308 · Complete and Submit proof of most recent training in the areas of Medication Handling, Dispensing, and Proper Documentation. · Proof of submission to include name of outside vendorized trainer, topics covered with duration of training, and list of all attendees by · Complete and submit proof of certified Administrator for this facility The licensee was able to provide the LIC 500 and LIC 308. Of the four staff members, only S4 had the certificates with the name of the vendor available. The topics covered under each subject was not available per the Administrator. LPA Campbell requested that the vendor be contacted for the topics covered for each class under any vendor who provided training on Medication Handling, Dispensing and Proper Documentation. One staff member (S3) was trained by the administrator who created a certificate for the staff member. The administrator (S1) and a pending administrator (S2) stated that the training was provided under their administrator training. LPA Campbell conducted a tour of the facility to confirm completion of tasks from the Facility Annual, Technical Assistance consult completed on 2/12/24. The licensee has cleared the backyard debris, completed the install of the new rug, printed out the FPCL for the administrator and included the signed employee rights form for each staff member. At this time, the administrator will also provide fingerprint clearance for the rest of her staff (LPA Campbell confirmed online that all staff were cleared beforehand.) and verify their medication training with the vendor and obtain the list of topics included in the training, including the administrator training. Per the California Code of regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited. Exit interview held with Administrator, copy of report left at facility.the state’s words, verbatim · CDSS document, Feb 16, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to this facility to conduct an annual inspection on 02/12/2024 at 9:15 am. LPA met with Stephen Hardin, House Manager and Georgia Wilcombe, Administrator and stated the purpose of today’s visit. LPA Campbell inspected the physical plant to ensure compliance with Title 22 regulations. The facility is licensed for 15 ambulatory and nonambulatory residents over 60. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. Though a ramp was observed for the entrance of the facility, no ramp was found through the back door to the patio and backyard. LPA Campbell also observed a burnt pile of wood and oranges. When asked about it, the House Manager stated that a client dumped the items from the yard there. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. While touring the office, a See Something Say Something poster was seen propped against a wall where it could not be viewed by residents or visitors. Per Licensee, the poster had become wet due to a now repaired washing machine. The licensee returned the poster to the wall during today's visit. The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 107 *F which is within the required range of 105-120*F. LPA observed a fire extinguisher(s) that was last inspected on 03/13/2023 and smoke and carbon monoxide detectors that were tested. Per California Code of Regulations (CCR), no deficiencies were observed. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2024

Allegation investigated: Facility has pests

On 11/15/23, 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. Based on observation during the tour of the facility LPA observed bedbugs in the room of R2. The licensee states they are using Terminex to rid the facility inside and out of pest, however, the facility is still active with bedbugs. Based on observation and interviews conducted the preponderance of evidence standards has been met, therefore, the above allegation(s) is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given. Substantiatedthe state’s words, verbatim · CDSS document, Nov 15, 2023 · control 27-AS-20231031120640

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 15, 2023

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not maintain the facility in a clean and sanitary condition. The facility currently has evidence of bedbugs. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: The licensee shall have a certified pest control company conduct a facility-wide bedbug treatment. The licensee shall send proof/invoice of bedbug inspection/treatment to LPA via email by 12/15/2023 The licensee shall create a schedule of routine pest control inspections and treatment to minimize the incidents. The licensee shall maintain proof/invoices of pest control inspectionsk and provide to Licensing upon request.