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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 12/28/2023
Date Signed: 12/28/2023 05:16:44 PM


Document Has Been Signed on 12/28/2023 05:16 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:LAGMAN, DONNAFACILITY TYPE:
740
ADDRESS:2194 BRISTOLWOOD LANETELEPHONE:
(408) 946-4454
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator, Donna LagmanTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit regarding an incident report. LPA met with Administrator, Donna Lagman and explained the purpose of the visit.

On December 27, 2023, the Department received an in incident report stating resident, R1 had a fall and was transported to the hospital via 911. R1 was in the Intensive Care Unit to monitor breathing and pain.

During visit, LPA Rai interview ADM, ADM stated R1 had an unwitnessed fall on 12/26/2023 at approximately 3am when S1 and S2 found R1 on the floor of R1's room. R1 complained of back pain but refused to go to the hospital. At approximately 7am, S1 and S2 check on R1 and decided to send R1 to the hospital via 911/ paramedics.

LPA interviewed 2 staff (S1 and S2).

LPA requested R1's Progress Notes which were documented starting 6/15/2023 and ending 9/3/2023, R1's Identification and Emergency Information, R1's After Discharge Summary 5/12/2023, R1's Appraisal and staff training pertaining to but not limited to observation of resident and emergency protocols.

This case management will be kept open pending investigation.

Exit interview was conducted with Administrator, Donna Lagman. A copy of this report was provided to Program Manager, Administrator, Donna Lagman.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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