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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000014
Report Date: 07/22/2022
Date Signed: 07/26/2022 10:26:38 AM

Document Has Been Signed on 07/26/2022 10:26 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:BRISBANE'S GUEST HOMEFACILITY NUMBER:
397000014
ADMINISTRATOR:GAPASIN, SEAN C.FACILITY TYPE:
735
ADDRESS:9512 BRISBANE PLACETELEPHONE:
(209) 952-9818
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 5DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Carmelo Ruiz - Direct Care StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection Visit. LPA met Direct Care staff and explained purpose of visit focusing on the facility's mitigation plan and infection control procedures. Administrator Esther Gapasin (Certificate # 6010498735 Expires 1/12/24). Facility has submitted a written mitigation plan (LIC 808) and LPA reviewed the plan for this infection control inspection. LPA and direct care staff toured the facility and reviewed the Mitigation Plan that has been submitted and is under review as well as discussing COVID Training Procedures during the Inspection.
Smoke alarms and smoke detectors are hard wired to the facility, were tested are operational. Fire extinguishers were serviced in 4/4/2022 and are in compliance. Facility has carbon monoxide detectors. Facility has a sprinkler systems. Medications were locked and facility was determined to have an adequate food supply. Facility's PPE supplies were determined to be adequate for a 30 day supply. The interior and outdoor area of the home was inspected including bedrooms, kitchen, bathrooms, and common areas for this home. There are five clients in the home and 4 client bedrooms. One care staff was present when LPA arrived for 5 clients with 3 bedrooms and 3 bathrooms.. Water temperature was tested at 108.4 degrees F. which is within the required range of 105 to 120 degrees.
LPA reviewed resident and 4 staff files, including criminal record clearances.
All staff today are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA was able to verify last documented fire drill was on 6/15/2022.
LPA requested updated copies of the following documents to be submitted via email by 9/22/22:
ruth.wallace@dss.ca.gov
LIC 308 Designation of Facility Responsibility, LIC 400 Affidavit Regarding Client Cash Resources, LIC 402 Surety Bond, LIC 500 Personnel Report, and Plan of Operation/Facility Program
LPA observed the following posted in the facility: Hand washing and visitation policies, Visitation signs are posted outside the home. Resident Personal Rights, Evacuation Routes and facility license were all posted as required.
Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, One deficiency was observed, see 809-D. Exit interview held with direct care staff and copies of reports and appeal rights were given at the conclusion of the inspection.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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Document Has Been Signed on 07/26/2022 10:26 AM - It Cannot Be Edited


Created By: Ruth Wallace On 07/22/2022 at 01:08 PM
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: BRISBANE'S GUEST HOME
FACILITY NUMBER: 397000014

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in Staff Room has stains, dirt, and grim on walls which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Licensee agrees to repaint the room completely by POC date of 9/22/2022. Copy of receipt for paint and pictures will be submitted to LPA via email by POC Date.
ruth.wallace@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


LIC809 (FAS) - (06/04)
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