<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000014
Report Date: 11/05/2024
Date Signed: 11/05/2024 12:03:04 PM

Document Has Been Signed on 11/05/2024 12:03 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:
11/05/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:GAPASIN, ESTELATIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 been completed. A copy of the training documents were provided to LPA Lewis. Licensee is out of the country until 11/26/24. Estela Gapasin will be filling in for the 20 hours a week that is required.

The LPA conducted a tour of the physical plant and observed 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.



Based on interviews, file reviews and observation of the physical plant, it appears the facility is operable at this time.

An exit interview was held with Estella Gapasin and a copy of the report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1