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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000014
Report Date: 04/12/2024
Date Signed: 04/12/2024 12:33:10 PM

Document Has Been Signed on 04/12/2024 12:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BRISBANE'S GUEST HOMEFACILITY NUMBER:
397000014
ADMINISTRATOR/
DIRECTOR:		GAPASIN, ESTELAFACILITY TYPE:
735
ADDRESS:9512 BRISBANE PLACETELEPHONE:
(209) 952-9818
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 5DATE:
04/12/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Estella GapasinTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 04/05/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit.
LPA reviewed


1. Conduct mandated reporting training in 6 months (Aug) then annually (Feb)
2. Conduct personal rights training by 03/01/24 then again in Aug then annually (Feb)
3. Administrator present 20 hrs week at each facility
4. Conduct Staff training occurs monthly regarding IPPs
5. Participate in TSP

Administrator states TSP has not contacted the facility as of yet. LIC 500 was emailed to LPA on 4/12/2024. Showing administrator hours present and home #1. Administrator will email LPA training records regarding IPP'S for months of February, March and April as they were available at the facility to review.

Exit interview conducted. Copy of report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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