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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390314725
Report Date: 10/27/2021
Date Signed: 10/28/2021 07:18:41 AM

Document Has Been Signed on 10/28/2021 07:18 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 #4FACILITY NUMBER:
390314725
ADMINISTRATOR:DARRELL J. GAPASINFACILITY TYPE:
735
ADDRESS:9757 NORTHRIDGE WAYTELEPHONE:
(209) 478-9400
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Darrell Gapasin, AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
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 LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by care staff who informed Administrator, Darrell Gapasin, of the LPA's visit and Mr. Gapasin arrived during the visit. LPA explained the purpose of the visit and staff and Mr. Gapasin accompanied LPA on the facility inspection.

LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6 There are 3 client bedrooms and 2 client bathrooms. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing and other signage noted. Medications noted to be locked to residents in care. LPA also conducted the infection control domain tool.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #4
FACILITY NUMBER: 390314725
VISIT DATE: 10/27/2021
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The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were checked March 2021 and are in compliance. Facility has an emergency food and water supply in a separate storage area in kitchen. All three care staff on-site had current fingerprint clearances.

LPA observed a package of bug killer unsecured in the back yard and paint and a household cleaner in the garage that was not locked

LPA requested the following documents to be updated: LIC 500 and LIC 309 as needed.

Per California Code of Regulations, one Title 22 deficiency was observed during this visit.

Exit interview was held and a report was given to Darrell Gapasin.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2021 07:18 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 10/27/2021 at 10:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GAPASIN MANOR #4
FACILITY NUMBER: 390314725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited abovewhich poses an immediate health, safety or personal rights risk to persons in care. LPA observed a package of bug killer in the back yard that was not locked and paint cans and a bottle of household cleaner in the garage that was not locked.
POC Due Date: 11/24/2021
Plan of Correction
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The hazardous items were secured while LPA was present. In-service training to be provided to care staff within 30 days and proof of training to be sent to LPA
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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