435200787-4-25-2023-26-AS-CDOS-CR8RNE-20230425131012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200787
Report Date: 04/25/2023
Date Signed: 04/25/2023 01:10:33 PM

Document Has Been Signed on 04/25/2023 01:10 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	BRIDLE'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	435200787
ADMINISTRATOR:	SEDIGH, G. MALOU		FACILITY TYPE:	735
ADDRESS:	2455 BRIDLE PATH DRIVE		TELEPHONE:	(408) 848-3711
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 6		CENSUS: 0	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Remedios Bose		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Administrator, Remedios Bose. During visit, LPA toured the facility with staff (S1) to include the family room, kitchen, dining room, living room, garage, laundry room, bathrooms, resident bedrooms, and backyard. All fire exit routes and passageways were free and clear of obstruction. Facility staff present and live-in staff are fingerprint cleared and associated to the facility. Facility temperature maintained at 70 degrees Fahrenheit. Fire Extinguisher last serviced on 07/29/2022. Facility has an operable carbon monoxide detector. Sharp objects observed secured. Medications observed in a locked cabinet. Chemicals, disinfectants, and toxins observed locked in the laundry room. Kitchen supplied with clean plates, bowls, cups, utensils, and cooking supplies. Facility has at least 7 days worth of non perishable foods and 2 days worth of perishable foods. Food storage containers observed with a lid and labeled. Facility does not have a thermometer inside the refrigerator and freezer to record temperature. Administrator was advised. Hot water at the kitchen sink was maintained at 100.4 degrees Fahrenheit. Bathrooms supplied with hygiene products, paper supplies, and lidded trash bins. Toilets and shower observed clean and sanitary. Hot water temperature at the bathroom sink maintained at 98.7 degrees Fahrenheit. Administrator and staff (S2) adjusted the hot water temperature during visit. LPA observed the hot water temperature was adjusted and maintained at 115.1 degrees Fahrenheit. Administrator was advised. SEE LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRIDLE'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200787
	VISIT DATE: 04/25/2023

NARRATIVE

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Resident bedrooms observed clean and well-kept. Bedrooms equipped with beds, linens, dressers, closets, adequate lighting, and night stands. LPA observed the facility has a sufficient amount of clean linens and cloths.

Facility has an emergency disaster plan. LPA observed the residents grab-and-go backpack and emergency bin located in the closet. Facility's last emergency drill was conducted on 04/2022. Administrator was advised.

LPA reviewed 3 resident (R1 - R3) files to contain the following: face sheet, emergency information, admission agreement, physician's report, TB, appraisal needs and services plan, personal rights, consent forms, weight record, immunization, safeguard of personal property and valuables, safeguard of cash resources, and centrally stored medication records. LPA inspected R1 - R3's P&I money and centrally stored medications.

LPA reviewed 3 staff (S1, S3 - S4) files to contain the following: health screening record, TB, criminal record statement, 1st aid certification, and training records. LPA did not observe staff were provided annual training to include medication administration. Administrator states they have an upcoming training scheduled with the Regional Center on 05/01/2023. Administrator was advised.

No clients observed on-site. Administrator states they are all attending day program. 2 staff were interviewed.

Documents to be submitted to LPA Dolores includes change of Administrator documents. See LIC9102.

A deficiency is being cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Administrator, Remedios Bose and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2023 01:10 PM - It Cannot Be Edited

Created By: Christine Dolores On 04/25/2023 at 12:50 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRIDLE'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200787
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the facility's hot water temperature was maintained between 98.7 - 100.5 degrees Fahrenheit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	During visit, Administrator adjusted the water temperature to 115.1 degrees Fahrenheit. Licensee will submit a plan in writing to ensure the facility's hot water temperature is maintained at a proper temperature. Licensee will submit the POC to LPA Dolores by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Sarah Yip

LICENSING EVALUATOR NAME:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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