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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000613
Report Date: 04/21/2022
Date Signed: 04/21/2022 10:48:39 AM

Document Has Been Signed on 04/21/2022 10:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BRISBANE GUEST HOME #2FACILITY NUMBER:
397000613
ADMINISTRATOR:GAPASIN, SEAN C.FACILITY TYPE:
735
ADDRESS:2420 CHAPEL HILL CIRCLETELEPHONE:
(209) 957-6019
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 4DATE:
04/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Esther Gapasin, AdministratorTIME COMPLETED:
09:20 AM
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Licensing Program Analyst Bruce Jacobs conducted a case management visit to the facility and met with facility administrator Esther Gapasin and care home staff.. The purpose of the visit with to ensure the facility is in compliance with applicable Department of Industrial Relations and Community Care Licensing statures and regulations..

During the visit, LPA spoke with the administrator and interviewed staff. LPA also reviewed records and observed the physical property and interacted with the clients. Based on interviews, observation of the physical plant and observations, it appears that the facility is in compliance with regulations and statutes. The food has the required signage and adequate amount of food. Two staff rooms were viewed and meet licensing standards.

Therefore the facility appears there are no observable deficiencies.

An exit interview was conducted with Esther Gapasin and a copy of this reported was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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