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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005073
Report Date: 04/14/2021
Date Signed: 04/14/2021 11:06:25 AM

Document Has Been Signed on 04/14/2021 11:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SONIA'S CARE HOME 4FACILITY NUMBER:
397005073
ADMINISTRATOR:GAPASIN, SONIAFACILITY TYPE:
740
ADDRESS:2988 APPLING CIRCLETELEPHONE:
(209) 609-9342
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: DATE:
04/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sonia Gapasin, AdministratorTIME COMPLETED:
11:25 AM
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Licensing Program Analysts (LPAs) Bruce Jacobs and Michael Bilger arrived at the facility to follow up of on an incident report that was submitted by the facility to Licensing. The incident report was on the death of client (C-1) who choking on food at the home. LPAs met with Facility Administrator Sonia Gapasin as well as the care staff involved in the incident. LPA's discussed the incident,

LPAs conducted additional interviews with facility staff, management and reviewed client file. Copies of file documents obtained. The LPAs requested any internal investigative reports conducted by the facility.

At this time, this case management information will be reviewed with the Licensing office . LPAs will require additional time before completing the review of this incident.

Exit interview conducted with the Administrator. Copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2021
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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