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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701399
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:21:10 PM

Document Has Been Signed on 09/26/2024 12:21 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:BANBURY HOUSEFACILITY NUMBER:
392701399
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, THOMAS J.FACILITY TYPE:
735
ADDRESS:215 BANBURY DRIVETELEPHONE:
(415) 272-8970
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 0DATE:
09/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:33 AM
MET WITH:T. RodriguezTIME VISIT/
INSPECTION COMPLETED:
12:34 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived announced to conduct a Pre-Licensing Inspection. LPA was allowed entry into the home that will be licensed for a capacity of 4 ambulatory residents. LPA met with Drew and Thomas who assisted with today's visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are no residents at this time.

LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 70*F which is within the required range of 68-85*F.

LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises.
The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home. Facility has central heating and air.

LPA observed the area where the staff and resident files are locked and readily available for review. Component III conducted.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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