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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000613
Report Date: 11/12/2024
Date Signed: 11/22/2024 10:32:03 AM

Document Has Been Signed on 11/22/2024 10:32 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/
DIRECTOR:		GAPASIN, SEAN C.FACILITY TYPE:
735
ADDRESS:2420 CHAPEL HILL CIRCLETELEPHONE:
(209) 957-6019
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: DATE:
11/12/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Rosete MarietesTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 011/12/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit.
LPA reviewed


1. Conduct mandated reporting training in 6 months (Aug) then annually (Feb)
2. Conduct personal rights training by 03/01/24 then again in Aug then annually (Feb)
3. Administrator present 20 hrs week at each facility
4. Conduct Staff training occurs monthly regarding IPPs
5. Participate in TSP

Administrator states TSP has contacted the facility. An updated LIC 500 will be emailed to LPA by 11/14/2024. Showing administrator hours present and home #1. training records were available at the facility to review.

Exit interview conducted. Copy of report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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