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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200274
Report Date: 08/26/2022
Date Signed: 08/26/2022 05:26:25 PM

Document Has Been Signed on 08/26/2022 05:26 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ferdinand Ramirez, Direct Care StaffTIME COMPLETED:
05:40 PM
NARRATIVE
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On 8/26/2022 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Direct Care Staff, Ferdinand Ramirez. LPA spoke with Administrator, Vanessa Kruse and was informed that she cannot be present at the facility.

Upon entry, LPA's temperature was checked and asked to fill out visitor's log. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All bathrooms were equipped with soap, paper towel, and garbage bin with lid. Hand washing posters were posted at sinks and bathrooms.

During record review, LPA observed visitors log and temperature log for staff. Client's temperature log was on the computer and staff was unable to access during inspection. LPA observed facility has a copy of Mitigation Plan on file. LPA observed staff were FIT tested in July 2022. LPA observed PPE, food supplies, and paper supplies are sufficient.

At 3:30PM, LPA observed unlocked cleaning supply cabinet under the kitchen sink. Staff locked up cleaning supply cabinet during inspection.

At 3:45PM, LPA observed lots of items along the side yard near the exit gate including old furniture, shower chair, pallets, boxes, and other items.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/26/2022 05:26 PM - It Cannot Be Edited


Created By: Grace Luk On 08/26/2022 at 04:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRISTOL PLACE
FACILITY NUMBER: 019200274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies under the kitchen sink which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/27/2022
Plan of Correction
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Staff locked up the cleaning supply cabinet during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/26/2022 05:26 PM - It Cannot Be Edited


Created By: Grace Luk On 08/26/2022 at 04:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRISTOL PLACE
FACILITY NUMBER: 019200274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having items that needed to be discarded along the side yard near the exit gate which poses a potential health and safety risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Administrator agreed to remove those items along the side yard including old furniture, shower chair, pallets, boxes, and other items. Administrator will submit picture proof and LIC9098 to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4