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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701195
Report Date: 11/10/2022
Date Signed: 11/10/2022 12:26:35 PM


Document Has Been Signed on 11/10/2022 12:26 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:BANCI'S GUEST HOMEFACILITY NUMBER:
502701195
ADMINISTRATOR:PANCHO, PEDROFACILITY TYPE:
740
ADDRESS:5120 SAINT CLARE CIRCLETELEPHONE:
(408) 838-3949
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:6CENSUS: 0DATE:
11/10/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:PANCHO, PEDROTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Kesha Lewis and Albert Johnson conducted an announced Pre-Licensing Inspection visit on 11/10/2022.

LPA was allowed entry into the facility that will be licensed for a capacity of 4 ambulatory and 2 non-ambulatory residents. LPA met with Mike Banci licensee, Pancho, Pedro future administrator 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. An in ground pool is in the back yard that is not fenced and not locked the lead time for getting a new pool fence is 5-6 weeks due to COVID supply chain shortages. LPA observed there are no residents at this time.

LPA observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, garage, and laundry room. In the garage there are unlocked toxins, administrator will build cabinets that will inclose the toxins. LPA observed knives/sharps, medications, and records storage to be locked. LPA observed required furniture, and lighting throughout the facility.

LPA will Return at a later date to conform the fence and cabinets are completed.

Comp III was completed.

An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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