435200787-4-25-2025-26-AS-CKAI-DG3QNJ-20250425121914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200787
Report Date: 04/25/2025
Date Signed: 04/25/2025 12:19:25 PM

Document Has Been Signed on 04/25/2025 12:19 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/ DIRECTOR:	REMEDIOS BOSE		FACILITY TYPE:	735
ADDRESS:	2455 BRIDLE PATH DRIVE		TELEPHONE:	(408) 848-3711
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 6		CENSUS: 4	DATE:	04/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Remedios Bose		TIME VISIT/ INSPECTION COMPLETED:	12:25 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	At 09:35am, Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required 1 year annual inspection. There were no residents and staff at the facility. LPA called the Administrator, Remedios Bose who met LPA at the facility at 10:00am. During visit, LPA toured the facility with the ADM to include the entrance, living room, family room, 2 staff bedroom, bathrooms, 3 resident bedrooms, laundry room, kitchen and exterior. LPA observed a circle glass table blocking the exit way from the family room to backyard; and a love seat couch blocking the exit way from the staff room to backyard. Administrator immediately moved the items from the exit way. In the kitchen, LPA observed the refrigerator and freezer was locked by a chain and masterlock. Administrator states they lock the refrigerator because there is 1 resident who has a behavior in drinking and dumping the beverages in the refrigerator. Facility did not inform the Department on their plan to lock the refrigerator. Administrator immediately removed the chain and masterlock on the refrigerator and was advised of the resident's personal rights. Refrigerator temperature maintained at 40 degrees F. Freezer temperature maintained at 0 degrees F. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Facility purees food for certain residents, which are stored in a storage container with lid. LPA advised Administrator to label the puree foods to include the date the puree was made. Administrator states the puree food was made yesterday. During visit, Administrator labeled the containers. Sharp objects, chemicals and disinfectants observed locked. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/25/2025

NARRATIVE

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Facility temperature maintained at 61 degrees F. Administrator states they adjust the temperature to 68 - 70 degrees F before the residents return from day program. Resident bedrooms observed well maintained with beds, linens, dressers, night stand and adequate lighting. Showers equipped with non-slip mats. Bathroom hot water temperature in the hallway maintained at 108.5 degrees F. Administrator states they have not had any issues regarding their water supply.

Fire extinguisher last serviced on 06/12/2024. Carbon monoxide detector present and operable. Facility has an emergency disaster plan. Residents has their own grab and go bags supplied with multiple items not limited to food and water, first aid kit, blanket, flash lights, and radio. Emergency drills are completed quarterly and the last drill was completed on 03/2025. Facility has an infection control plan. PPE supplies observed to include a mask, gowns, and gloves.

LPA reviewed 4 resident files. 4 out of 4 resident files observed complete and up-to-date. LPA reviewed 4 out of 4 residents P&I money with the ADM and no issues noted. 4 out of 4 residents centrally stored medications and records were reviewed and no issues noted.

LPA reviewed 3 staff files. 3 out of 3 staff files contains a health screening record, TB result, criminal record statement, job application, active 1st aid certification, and annual training records.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Remedios Bose and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2025 12:19 PM - It Cannot Be Edited

Created By: Christine Kabariti On 04/25/2025 at 11:54 AM

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: 04/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 counts wherein LPA observed 2 exit doors was obstructed with furniture which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2025
	Plan of Correction
1 2 3 4	Licensee immediately moved the furnitures blocking the 2 exit ways. Licensee will submit a statement of understanding of the section cited above, to LPA Kabariti via email by POC due date.

Type A

Section Cited

CCR

80072(a)(3)

(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from … interference with the daily living functions, including eating, sleeping, or toileting; …. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above wherein the LPA observed the refrigerator was locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2025
	Plan of Correction
1 2 3 4	Licensee states they will find other ways to deter the resident's behavior from accessing the refrigerator. Licensee will submit a statement of understanding regarding resident rights, to LPA Kabariti via email by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC809 (FAS) - (06/04)

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