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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000613
Report Date: 12/04/2023
Date Signed: 12/04/2023 04:06:13 PM

Document Has Been Signed on 12/04/2023 04:06 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, 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: 5DATE:
12/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Marieates RoseteTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted a case management inspection of BRISBANE'S GUEST HOME #2. LPA met with Marieates Rosete regarding an incident report faxed to CCL on 11/06/2023

R1 was sent to the hospital due to urinary retention, and returned some day to the facility with a Foley catheter. R1 was sent to the hospital on 11/4/2023 and seen by a nurse at the facility on 11/17/23. On 11/14/23 R1 was seen by there Docror for a follow up visit at that visit the catheter was changed. R1 was seen again by the doctor on 11/21/23, catheter was not changed at this visit. R1 has another appointment on 12/29/2023 to be seen by the doctor. Staff is not changing catheter only emptying the bag. The nurse has not returned to the facility.

LPA Lewis will return to the facility to get a copy of the discharge orders from the hospital, the orders were not at the facility they may have been left at the doctor. LPA Lewis requested that another copy of the orders be obtained by 12/12/2023.

This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.

Exit interview and report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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