<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701195
Report Date: 02/14/2024
Date Signed: 02/14/2024 01:10:05 PM


Document Has Been Signed on 02/14/2024 01:10 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: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: 1DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:staff Dino UbaldeTIME COMPLETED:
01:30 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
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met with staff Dino Ubalde and explained the reason for the visit. LPA Lund spoke with with Administrator Pedro Pancho who could not make the visit today and gave permission for staff Dino Ubalde to sign required paperwork. Census: 1

LPA Lund & staff Dino Ubalde toured/inspected the facility 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. 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 at 108 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. A file review of 2 staff & 1 resident was completed and were incompliance.



No deficiencies were observed during the visit. Exit interview and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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 1