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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200274
Report Date: 09/17/2025
Date Signed: 09/17/2025 04:31:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2025 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250731095321
FACILITY NAME:BRISTOL PLACEFACILITY NUMBER:
019200274
ADMINISTRATOR:VANESSA (KRUSE) RODRIGUEZFACILITY TYPE:
735
ADDRESS:5242 BRISTOL PLTELEPHONE:
(510) 792-5450
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:3CENSUS: 3DATE:
09/17/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Anthony Green, Regional DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not have required training
Staff are not documenting properly
Staff did not dispose of expired medications properly
Staff do not have physicians orders for medications
Staff did not ensure blinds were fixed
Staff are not ensuring the house is cleaned properly
INVESTIGATION FINDINGS:
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On this day at around 2:30 pm, LPA Luisa Fontanilla arrived unannounced to deliver finding for the above allegations and met with Anthony Green. LPA explained to Green the purpose of the visit.
During the course of investigation, the Department conducted interviews and reviewed records. On 8/6/2025, LPA conducted 10-day visit and obtained records. On 8/15/2025, LPA interviewed Area Director Jasmine Williams and one caregiver.

1. Staff did not have required training
Based on interview conducted and records reviewed, Staff 1(S1), who is the Supervisor, has expired First aid/CPR training while Staff 2 (S2) has not completed CPI training.
2. Staff did not dispose of expired medications properly
3. Staff are not documenting properly
On 8/15/2025, LPA interviewed the Area Director (AD) who confirmed with LPA that expired medications were not disposed of accordingly and that the facility does not have Centrally Stored Medication and Destruction Record (CSMDR).

continuation on Lic 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20250731095321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRISTOL PLACE
FACILITY NUMBER: 019200274
VISIT DATE: 09/17/2025
NARRATIVE
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3. Staff did not ensure blinds were fixed

4. Staff are not ensuring the house is cleaned properly

On 8/6/2025, LPA observed broken blinds in the living room and dusty windows. On the side exit, LPA observed rusty metal cages, broken computer and keyboard and unused chairs.

Staff interviewed confirmed with LPA the presence of urine sample dated 4/2024 in the medicine refrigerator . Also, shower chair with soap scum and rusty bathroom walls were observed during the RCEB Quality Assurance (QA) visit.

5. Staff do not have physicians orders for medications

Based on interview conducted with RCEB QA, the facility did not have doctor's order for all clients' medications on file for 2025.

Based on observations, record reviews and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations are being cited on the attached LIC 9099D.



Exit interview was conducted with Green and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250731095321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRISTOL PLACE
FACILITY NUMBER: 019200274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2025
Section Cited
CCR
80075(f)
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80075(f) Health Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
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By POC date, the facility will have staff complete training and submit proof to CCL.
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This requirement is not met as evidenced by: Based on record review conducted, S1 who is the supervisor has an expired first aid/CPR training which poses a potential risk to the health and safety of clients under care.
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Type B
09/24/2025
Section Cited
CCR
80075(k)(7)
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80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:
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The Administrator will make sure the facility has a complete and updated CSMDR and submit proof to CCL.
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This requirement is not met as evidenced by: Based on interview conducted, the facility did not have CSMDR which poses a potential risk to health and safety of clients under care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250731095321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRISTOL PLACE
FACILITY NUMBER: 019200274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2025
Section Cited
CCR
80075(l)
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80075 Health Related Services
(l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed ...
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By POC date, the Administrator will make sure all expired medications and medications that were not brought by former clients upon termination of services will be destroyed accordingly. Proof of corrections will be
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This requirement is not met as evidenced by: Based on interview conducted, the facility was observed with expired medications which poses a potential risk to health and safety of clients under care.
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sent to CCL.
Type B
09/24/2025
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by: Based on interview and LPA observation, the facility was observed with broken blinds, shower chair rusted and full of
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The facility will ensure that items not needed are disposed off properly, bathroom cleaned and window blinds fixed. The Administrator will submit proof of correction by POC date.
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soap scums; side passage way was observed with rusty metal cages, unused keyboard and monitor and chairs not in good condition.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4