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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005707
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:04:31 PM

Document Has Been Signed on 05/05/2023 03:04 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:KHAN GUEST HOMEFACILITY NUMBER:
397005707
ADMINISTRATOR:KHAN, HANIFFACILITY TYPE:
735
ADDRESS:12773 N LOWER SACRAMENTO ROADTELEPHONE:
(209) 329-5689
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sal Franz, House ManagerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Sal Franz, House Manager. The Administrator is Hanif Khan. The administrator currently holds a certificate (#6008266735) that expires on 12/04/2023. The fire extinguisher was inspected on 05/01/2023.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. The hot water temperature is maintained at 112 degrees Fahrenheit. All outdoor and indoor passageways were kept free from obstruction. Rooms were furnished appropriately. There was an adequate supply of toiletries, hygiene supplies, and extra linens. There is a minimum of 7-day nonperishables and 2-day perishables foods.

The last disaster/fire drill was conducted on 03/07/2023. Fire extinguishers, smoke detectors and carbon monoxide were checked. LPA reviewed 3 of 6 record files and the facility has sufficient staffing to provide the services needed to meet the clients’ needs. All staff have criminal record clearance and are associated to the facility. No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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