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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 390309907
Report Date: 08/01/2023
Date Signed: 08/02/2023 11:12:54 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2023 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230622082116
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: 5DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not following the posted menu.
Facility staff are not documenting substitutions made to the posted menu
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the above allegations. LPA was greeted by staff and explained the reason for the visit.

Based on LPA observation and interviews with S1 and residents R1-R2 allegation 1 - Facility staff are not following the posted menu and allegation 2- Facility staff are not documenting substitutions made to the posted menu are unsubstantiated. While the facility had ingredients, the ability and the time to prepare what was posted on the menu, staff are substituting meals by the request of the residents. A finding of UNSUBSTANTIATED means the preponderance of evidence standard is not met.

Exit interview conducted. copy of report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 1