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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:39:07 PM

Document Has Been Signed on 09/19/2024 01:39 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:BRISTOLWOOD HOMEFACILITY NUMBER:
435202404
ADMINISTRATOR/
DIRECTOR:		LAGMAN, DONNAFACILITY TYPE:
740
ADDRESS:2194 BRISTOLWOOD LANETELEPHONE:
(408) 946-4454
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: DATE:
09/19/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Chief Executive Officer Song Cindy Chen and Chief Financial Officer Donna LagmanTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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A Noncompliance meeting was conducted on September 19th, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analyst Simi Rai, Chief Executive Officer Song Cindy Chen, and Chief Financial Officer Donna Lagman.

The purpose of the noncompliance meeting was to discuss the history of facility's serious violations cited under Title 22 California Code of Regulations to include Personal Rights, Incidental Medical and Dental Care, Care of Persons with Dementia, Personal Requirements and Administrator Qualifications and Duty.

Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections.

The San Bruno Adult and Senior Care - San Jose Unit will refer the facility for legal consultation which may result in administrative actions such as possible Administrator De-Certification, License Revocation, or Employee Exclusion.

Deficiencies were cited per California Code of Regulations, Title 22 during today's visit, please see LIC 809-D. Appeal Rights were provided.

Report was reviewed with Licensee representatives. A copy of this report, LIC 9111 was provided to Licensee representatives during today's office visit.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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 3
Document Has Been Signed on 09/19/2024 01:39 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/19/2024 at 12:13 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: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
87415(a)(1)

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87415(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises.
This requirement is not met as evidenced by:
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Licensee to submit a written plan of action to ensure night supervision and update LIC 500 by POC due date
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Based on review of LIC 500, Licensee admitted that on-call night staff is not awake to provide night supervision from 10:00pm to 6:00am, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
09/20/2024
Section Cited
CCR87205(a)

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87205(a)The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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Licensee to submit a written plan of action to ensure supervision over the affairs of the licensed facility and update LIC 500 by POC due date.
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This requirement is not met as evidenced by:
Based on interview, Licensee admitted that there was no general supervision over the affairs of the licensed facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 01:39 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/19/2024 at 12:21 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: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/20/2024
Section Cited
CCR
87625(b)(1)

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87625 (b) (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.
This requirement is not met as evidenced by:
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Licensee to submit a written plan of action to ensure a plan is created for resident's tolieting needs by POC due date.
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Based on interview, Licensee and Administrator stated resident R1 was placed in diaper at night instead of scheduled toileting at night with the on-call night staff which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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