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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 09/12/2022
Date Signed: 09/12/2022 11:49:41 AM


Document Has Been Signed on 09/12/2022 11:49 AM - 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:LAGMAN, DONNAFACILITY TYPE:
740
ADDRESS:2194 BRISTOLWOOD LANETELEPHONE:
(408) 946-4454
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 4DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Noel Bizon and Donna LagmanTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Noel Bizon and Donna Lagman.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed the facility to have a visitor screening area. The facility had a 30-day supply of PPEs. LPA Marrufo observed a perishable food supply of 2 days and a non-perishable food supply of 7 days. LPA Marrufo observed the hallway bathroom to have available soap and paper towels and a hand washing sign. LPA Marrufo toured the outside area of the facility and observed 2 out of 2 outdoor exits were free of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22.


This report was reviewed with Noel Bizon and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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