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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000613
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:32:40 PM

Document Has Been Signed on 11/29/2022 02:32 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 AC/SC, 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:
11/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marieates RoseteTIME COMPLETED:
02:45 PM
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On 11-29-22 , Licensing Program Analysts (LPA'S) Kesha Lewis and Albert Johnson arrived unannounced to conduct a case management visit.

The purpose of this case management was to do a health and safety check for the incident report received 11/16/2022 regarding a stove fire on 11/14/2022. LPA'S met with staff and explained the purpose of the visit.

Fire department was called and the house was cleared for residents to reenter (1) one hour later after smoke had cleared out. Stove and hood were replaced. No residents were displaced after the fire.

LPA'S conducted a tour through facility with staff to check fire clearance.

No deficiencies cited today. An exit interview was conducted with staff and a copy of this report was left.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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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