502701195-8-24-2023-27-AS-KVIA-CUZSKV-20230824135722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701195
Report Date: 08/05/2023
Date Signed: 08/24/2023 01:57:28 PM

Document Has Been Signed on 08/24/2023 01:57 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 HOME		FACILITY NUMBER:	502701195
ADMINISTRATOR:	PANCHO, PEDRO		FACILITY TYPE:	740
ADDRESS:	5120 SAINT CLARE CIRCLE		TELEPHONE:	(408) 838-3949
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	6	CENSUS: 1	DATE:	08/05/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Estrellita Banci		TIME COMPLETED:	03:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

An unannounced Post-Licensing visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 08/05/23. Due to technical difficulties, this report was done manually and not entered into FAS until 08/23/2023. The following was transcribed from the original report left at the facility.

LPA identified herself to the Caregiver on duty, explained the purpose of the visit, and asked to speak to the Designated Facility Administrator. The Caregiver called Estrellita Banci, Licensee, who stated that she would be at the facility shortly. Census at the time was 1 resident in care.

LPA noted the Designated Facility Administrator, Pedro Pacho’s, certificate (# 6061071740, expiration date 10/26/23) was posted in the living room along with the facility’s license, facility sketch and emergency disaster plan.

The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 7-day nonperishable and 2-day perishable. Opened packages were not dated and labeled in the refrigerator. LPA provided technical assistance. LPA selected 8 random items from the refrigerator, 3 of which had expired.

LPA inspected the 3 bedrooms, all had the required furniture, furnishings and lighting to be in compliance at this time. The LPA observed grab bars and non-skid surfaces in the 2 bathrooms along with paper towels and soap. The hot water was measured to ensure it was between 105 and 120 degrees Fahrenheit. The fire extinguisher was purchased 08/05/2023 at Home Depot and was in compliance.

The exterior of the building was inspected by the LPA. The yard was clear of debris and completely fenced in. The facility did have an in-ground pool which was completely fenced in and had 2 locked gates. Pool chemicals were stored in a separate locked gated area in the yard and inaccessible to residents in care. LPA also observed a covered patio are for residents to enjoy.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 502701195
	VISIT DATE: 08/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

A file review of the 4 individuals associate with the facility was completed as well. The primary Caregiver and the Designated Facility Administrator's files were complete. The remaining 2 files were for the Licensees and they were not providing care at this time.

According to the Code of California Code of Regulations, Title 22, Article 6, the following deficiency was observed and cited on the LIC 809 D page.

A copy of this report and Appeal Rights were provided.

Exit interview.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/24/2023 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 502701195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/08/2023 Section Cited CCR 87555(b)(9)	1 2 3 4 5 6 7	Food Service CCR 877555(b)(9) (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee will develop a monthly schedule to clean out the refrigerator and will submit it to kimberly.viarella@dss.ca.gov by 08/08/2023.
	8 9 10 11 12 13 14	Licensee failed to protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service when the LPA observed 3 out of 8 items in the refrigerator had expired. This posed/poses a health, safety and personal rights risk to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3