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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390313073
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:32:35 PM

Document Has Been Signed on 10/21/2022 02:32 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
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:
10/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:FranciscoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst Albert Johnson met with Staff to conduct a follow up visit related to respite care.

The Department conducted a case management visit for a health and safety check. R1 was sleeping when the safety check was completed. The facility will be using Holistic Home health to monitor and maintain R1's diabetic needs.

This will be a temporary residence for R1, until the R1's home is repaired. The incident.
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Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were observed during this visit.

Exit interview held and a report given at the conclusion of the visit
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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