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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200274
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:03:29 PM

Document Has Been Signed on 07/20/2023 03:03 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:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Pele Martin, Program Supervisor TIME COMPLETED:
03:15 PM
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On this day at around 9:40 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and was met by Program Supervisor Pele Martin and staff Preston Hart. LPA explained to staff the purpose of the visit. Area Director Rosemary Maurillo was informed over the phone. Both Area Director and Program Administrator were unavailable during the visit. Quality Improvement Specialist Diane Truong arrived at around 11am to assist LPA with the visit.

At around 10am, LPA inspected the facility inside and out including but not limited to 3 client rooms, 2 bathrooms, dining area, kitchen and backyard. Hot water measured at 105.5 degrees Fahrenheit in the kitchen and common shower room. Non skid mats and grab bars were observed in the shower room. There were smoke detectors observed in all client rooms. Fire extinguisher by the kitchen was observed full and last inspected on 9/22/2022. Medications were observed locked in the hallway cabinet. Sufficient supply of perishable and non perishable foods were observed.

LPA spoke with Rosemary Maurillo who states the facility does not keep P&I money on site. She states monies are kept in a bank and that clients have debit cards and go to the bank, if needed. LPA reviewed P&I money log. Facility has a surety bond in the amount of $5,000.

At 10:45 am, LPA reviewed 3 client files and 5 staff files. At around 11:30 am, LPA reviewed P& I log.

LPA interviewed one client and one staff during the visit.

No deficiencies were noted during this visit.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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