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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397000014
Report Date: 02/01/2024
Date Signed: 02/01/2024 01:29:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2023 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230911140120
FACILITY NAME:BRISBANE'S GUEST HOMEFACILITY NUMBER:
397000014
ADMINISTRATOR:GAPASIN, ESTELAFACILITY TYPE:
735
ADDRESS:9512 BRISBANE PLACETELEPHONE:
(209) 952-9818
CITY:STOCKTONSTATE: ZIP CODE:
95209
CAPACITY:6CENSUS: 5DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Carmelo ruizTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility Staff are sexually abusing resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the above allegations. LPA was greeted by staff and explained the reason for the visit.

Allegation 1 Facility Staff are sexually abusing resident is SUBSTANTIATED. The department conducted an investigation that consisted of interviews and record reviews. Based on interview, R1 informed S2, S3, and S4 that S1 had touched their private areas. In addition, R1 reported that their private area was touched during multiple interviews by the local PD. Five (5) facility staff members were interviewed, one (1) out of five (5) staff confirmed a similar incident happened about 6 months before with S1 and a former resident. Based on interviews conducted, and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED.


Continued on the 9099C.....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
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 3
Control Number 27-AS-20230911140120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 397000014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
HSC
1569.2(c)
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1569.2(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by:
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 All staff have concluded their training on mandating reporting. Administrator will give copies of In-service training by 02/05/24.
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Based on interview, record review, and observation, the Licensee did not ensure residents were protected from S1's sexual inappropriate behavior and touching. This poses an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230911140120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 397000014
VISIT DATE: 02/01/2024
NARRATIVE
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Per California Code of Regulations, Title 22 Division 6, Chapter 8 ,and California Health and Safety Code. Deficiencies are being cited on the attached 9099-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.

LPA also delivered the NCC request letter.

Exit interview conducted, a copy of this report, LIC 9099-D, and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3