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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701195
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:29:27 PM


Document Has Been Signed on 02/09/2023 12:29 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:
02/09/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:PANCHO, PEDROTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Kesha Lewis conducted an announced Pre-Licensing re- Inspection visit on 02/09/2023.

This LPA was present to follow up on the previous Prelicensing visit conducted on 11/10/2022 to make sure the following items were brought into compliance:

LPA return to confirm the fence around the pool in the backyard and cabinets in the garage were completed. Photos taken.

Based on today's Prelicensing visit this facility has been found to be in compliance at this time.

Exit Interview conducted and copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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