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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390309907
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:19:56 PM

Document Has Been Signed on 03/22/2024 03:19 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:GAPASIN'S MANORFACILITY NUMBER:
390309907
ADMINISTRATOR:GAPASIN, VIOLETAFACILITY TYPE:
735
ADDRESS:3817 RION WAYTELEPHONE:
(209) 477-1063
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 4DATE:
03/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cosme SanaTIME COMPLETED:
03:30 PM
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On 3-22-24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit regarding incidents which occurred on 2-24-24. LPA met with staff and explained the purpose of the visit. LPA reviewed incident reports dated 2-24-24 and facility file documentation for resident 1 (R1). LPA also conducted health and safety facility tour as part of this case management. Additionally, LPA interviewed staff.

On 2-24-24, facility reported that, R1 was not found to not be responsive during round. Facility provided for LPA Lewis R1'S IPP, 602 (physician report) and annual review of R1. LPA conducted facility tour with staff. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Staffing levels included, 3 caregivers. Room temperature was 71*F. Smoke alarms and carbon detectors are functioning properly. Current census is 4. No obstructions to fire exits noted during today's tour. As a result of today's case management visit, no deficiencies are being cited under Title 22, Division 6, Chapter 8. Facility will email LPA a copy of the DNR for R1.


Kesha.lewis@dss.ca.gov

An exit interview was conducted with staff and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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