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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000014
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:52:01 PM

Document Has Been Signed on 07/26/2023 03:52 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, ESTELAFACILITY TYPE:
735
ADDRESS:9512 BRISBANE PLACETELEPHONE:
(209) 952-9818
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
07/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Gregoria Bala TIME COMPLETED:
03:30 PM
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
Licensing Program Analyst (LPA) Kesha Lewis conducted a case management inspection of BRISBANE'S GUEST HOME. LPA met with staff to ensure the facility is in compliance with applicable statutes and regulations.

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.

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

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: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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