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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000613
Report Date: 01/12/2024
Date Signed: 01/18/2024 11:36:18 AM

Document Has Been Signed on 01/18/2024 11:36 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 5DATE:
01/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH: Marieates RoseteTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Kesha Lewis conducted a case management inspection of BRISBANE'S GUEST HOME #2. 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 5. 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: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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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