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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390313073
Report Date: 03/25/2022
Date Signed: 03/29/2022 06:03:32 AM

Document Has Been Signed on 03/29/2022 06:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GAPASIN MANOR #3FACILITY NUMBER:
390313073
ADMINISTRATOR:GAPASIN, VIOLETA T.FACILITY TYPE:
735
ADDRESS:2211 SANDRINGHAM WAYTELEPHONE:
(209) 951-1124
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 5DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Darrell Gapasin, Facility AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analysts (LPA) Bruce Jacobs arrived at the facility to follow up of on an incident report that was submitted by the facility to Licensing. The incident report was on the death of client (C-1) who passed at the hospital. LPA met with Facility Administrator Darrell Gapasin as well as the care staff. LPA discussed the incident.

LPAs conducted additional interviews with facility staff, management and reviewed client file. Copies of file documents obtained. The client complained of pain on 2/16/22 and the facility called the client's Physician who advised the facility to take the client to be seen at the hospital. Client was taken to the hospital and was treated for sepsis. On March 17th the client was placed on hospice while still in the hospital and given comfort care and passed on 3/21/22 at the hospital

At this time, this case management information will be reviewed with the Licensing office

Exit interview conducted with the Administrator. Copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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