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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000613
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:25:37 PM

Document Has Been Signed on 04/12/2024 02:25 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 #2FACILITY NUMBER:
397000613
ADMINISTRATOR/
DIRECTOR:		GAPASIN, SEAN C.FACILITY TYPE:
735
ADDRESS:2420 CHAPEL HILL CIRCLETELEPHONE:
(209) 957-6019
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 5DATE:
04/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Esther GapasinTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 4-12-24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit regarding incidents which occurred on 3-18-24. LPA met with licensee and explained the purpose of the visit. LPA reviewed incident reports dated 3-19-24 and facility file documentation for resident (R1). LPA also conducted health and safety facility tour as part of this case management. Additionally, LPA interviewed licensee Esther Gapasin.

On 3-19-24, facility reported that on 3-18-24, R1 was found about 6:00 AM sitting on the floor of his room when staff went to wake R1 and give them a shower. When attempting to remove R1's clothing for the shower it was observed that R1 could not lift their arm. Staff then called licensee and informed her and she then took R1 to the emergency room arriving around 9:00 AM. It was found that R1 has a fractured arm. R1 has a current 602 (Physicians Report) and IPP, interviews of S1-S2 were contestant. Resident had a follow up visit with an orthopedic doctor and sugary will not be needed.

LPA conducted facility tour staff. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Staffing levels included 2 direct care and the administrator. Fire extinguisher was full charged and dated 07-20-23. Room temperature was 72*F. Smoke alarms and carbon detectors are functioning properly. Current census is 5. No obstructions to fire exits noted during today's tour.

An exit interview was conducted with Esther Gapasin and a copy of this report was given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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