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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 12/27/2024
Date Signed: 12/27/2024 10:50:01 AM

Document Has Been Signed on 12/27/2024 10:50 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/
DIRECTOR:		LAGMAN, DONNAFACILITY TYPE:
740
ADDRESS:2194 BRISTOLWOOD LANETELEPHONE:
(408) 946-4454
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 4DATE:
12/27/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Corporate Officer/Licensee Song Cindy Chen and Corporate Officer/Administrator Donna LagmanTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Corporate Officer/Licensee Song Cindy Chen and Corporate Officer/Administrator Donna Lagman. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an Noncompliance Conference meeting held on 9/19/2024. LPA Rai observed 4 residents and 3 staff at the facilty, including the Corporate Officer/Licensee and Corporate Officer/Administrator.

During visit, LPA Rai reviewed the LIC 500 to observe 1 on-call staff and 1 awake staff on shift during the NOC shift which includes the hours of 10pm to 6am daily. LPA Rai reviewed the LIC 500 to observe Corporate Officer/Licensee and Corporate Officer/Administrator shifts at the facility.

LPA Rai reviewed the caregiver daily activity log for the month of November. The log included staff checking on the residents every 2 hours in the AM/PM shift and every 4 hours during NOC shift. The log also included the staff turnover system where staff are able to discuss medication administration, Activities of Daily Living (ADLs) provided to the residents, and any emergency that may occur during shift. Corporate Officer/Administrator stated back-up Administrator, Sam Sinio reviews the caregiver daily activity log every Tuesdays, she reviews the logs every Thursdays and Fridays and Corporate Officer/Licensee reviews it every month.

LPA Rai reviewed the medication tracking system to ensure all residents have enough supply of medication. LPA Rai observed the tracker documents all the tablets that are in the bottle every day. Corporate Officer/Licensee stated she reviews all resident's medications on a weekly basis and back-up Administrator, Sam Sinio reviews the medication tracking record and medication administrator record for accuracy and update.
Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 2
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: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404
VISIT DATE: 12/27/2024
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LPA Rai reviewed progress notes for the residents for the months of November and December. Corporate Officer/Administrator Donna stated three staff members are designated to write the progress notes of the residents, which include herself, Corporate Officer/Licensee Cindy and back-up Administrator Sam. Donna stated the three of them will discuss the residents' current condition and review the caregiver's daily activity log and update the resident's Appraisal/Needs and Service Plan as necessary.

During today's visit, LPA Rai observed 2 locked cabinets in the kitchen which stored toxins and chemicals inaccessible to residents in care. LPA Rai observed 1 locked cabinet in the bathroom which stored toxins and chemicals inaccessible to residents in care. LPA Rai observed 1 locked storage cabinet in the laundry area which stored toxins and chemicals inaccessible to residents in care.

No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Corporate Officer/Licensee Song Cindy Chen and Corporate Officer/Administrator Donna Lagman and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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