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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000014
Report Date: 09/13/2023
Date Signed: 09/13/2023 10:30:49 PM

Document Has Been Signed on 09/13/2023 10:30 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: 5DATE:
09/13/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:10 PM
MET WITH:Gregoria BalTIME COMPLETED:
10:40 PM
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LPA'S Kesha Lewis and Maja Jenson made an unannounced health and safety check. LPA'S met with Staff. LPA'S explained the purpose of the visit to conduct a health and safety check of the facility.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. The facility has a sufficient 2 day supply of perishable food and 7 day Non-perishable food.


Exit interview was conducted and a copy of report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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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