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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000014
Report Date: 03/30/2023
Date Signed: 03/30/2023 02:47:58 PM

Document Has Been Signed on 03/30/2023 02:47 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 AC/SC, 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: 6DATE:
03/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Carmello Ruiz TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted a case management inspection of BRISBANE'S GUEST HOME. LPAs met with Carmello Ruiz to ensure the facility is in compliance with applicable statutes and regulations.

During the visit, the LPA conducted interviews with staff. based in interviews the staff is not being paid for night hours or overtime and are not getting breaks. pay checks are received on time but not for the right amount.

The LPA reviewed staff/resident files and resident medications and observed all medications to be locked and inaccessible to residents in care.

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. Facility is a 6 bed facility with a current census of 6. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals noted to be locked to residents in care.

Based on interviews, file/medication reviews, and observation of the physical plant, it appears the facility is operable.

An exit interview was held and a copy of the report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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