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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 390314725
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:36:06 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
09/12/2023 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20230912134315
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:
11/15/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Zandra Mae VillegasTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident is being sexually abused by an unknown perpetrator.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to the facility to deliver complaint investigation findings. LPA met with facility staff and explained the purpose of the visit.

The department conducted an investigation and has determined the following as it related the above fore mentioned allegation.

On On 09/08/2023, Resident 1 (R1) was seen at St. Joseph’s Hospital, located at 1800 N California St, Stockton, CA. R1 was brought to the hospital by caregivers, S1 and S2. R1 was admitted the next day. A computerized tomography (CT) scan was performed on R1 and a plastic tube was seen in the vagina. The staff did not know why it was there. Interviews were conducted and medical records obtained. R1'S final diagnosis was a urinary tract infection (UTI).

Continued on 9099c page.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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 2
Control Number 27-AS-20230912134315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GAPASIN MANOR #4
FACILITY NUMBER: 390314725
VISIT DATE: 11/15/2023
NARRATIVE
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Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED.  Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was held with Facility Staff and report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC9099 (FAS) - (06/04)
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