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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397000613
Report Date:
01/09/2024
Date Signed:
01/22/2024 05:31:59 PM
Document Has Been Signed on
01/22/2024 05:31 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
BRISBANE GUEST HOME #2
FACILITY NUMBER:
397000613
ADMINISTRATOR:
GAPASIN, SEAN C.
FACILITY TYPE:
735
ADDRESS:
2420 CHAPEL HILL CIRCLE
TELEPHONE:
(209) 957-6019
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95209
CAPACITY:
6
CENSUS:
DATE:
01/09/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:27 PM
MET WITH:
TIME COMPLETED:
01:28 PM
NARRATIVE
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See report dated 01/12/2024.
SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Kesha Lewis
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/09/2024
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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