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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202440
Report Date: 08/18/2025
Date Signed: 08/18/2025 05:33:57 PM

Document Has Been Signed on 08/18/2025 05:33 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:BLUE RIDGE RCHFACILITY NUMBER:
435202440
ADMINISTRATOR/
DIRECTOR:		FREDRICKA SAFARFACILITY TYPE:
735
ADDRESS:4209 BRIARGLEN DRIVETELEPHONE:
(415) 385-8900
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
08/18/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:05 PM
MET WITH:Licensee/Administrator Fredricka SafarTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst Simi Rai arrived at the facility unannounced to conduct a case management – other visit. LPA met with Licensee/Administrator Fredricka Safar. LPAs observed 3 staff members and 6 residents at the facility.

The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility and conclude the investigation visit from 7/29/2025.

S1 was not currently working in the facility. Licensee/Administrator Fredricka Safar stated the staff was terminated on 7/25/2025.

The immediate exclusion letter was handed to the Licensee/Administrator Fredricka Safar. Licensee/Administrator Fredricka Safar was informed to remove S1 from any contact with residents and not allow S1 to be physically present in the facility. The ADM was advised to separate S1 from the facility roster.

On 7/28/2025, the Department received an Incident Report stating on 7/25/2025 at approximately 5:40pm, staff S1 slapped resident R1 twice on the right side of the face, leaving a visible red mark. This incident was observed by staff S2 and S3 and they intervened and applied an ice pack to R1's face. Per report, S1's employment was terminated and no longer works at the facility. The Department conducted interview of 1 staff (S2). S2 stated he/she witnessed the incident wherein S1 slapped resident R1 twice on the right side of the face.

Continuation on LIC 809-C, Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2025
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 4
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: BLUE RIDGE RCH
FACILITY NUMBER: 435202440
VISIT DATE: 08/18/2025
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Page 2 of 2.

Administrator Fredricka Safar provided additional information for case management conducted on 7/15/2025. The Department will continue to investigate the case and provide determination at a later date.

Deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Licensee/Administrator Fredricka Safar and a copy of the report was provided. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/25/2026 02:59 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/29/2026 11:01 AM


Citations on this Visit Report are Under Appeal!


Created By: Simranjit Rai On 08/18/2025 at 04:55 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLUE RIDGE RCH
FACILITY NUMBER: 435202440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/19/2025
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a)(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, ...
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure resident is free of inflicton of pain which may be presented as physical abuse by POC due date. Licensee/Administrator agreed and understood.
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Based on interviews conducted,the licensee reported the incident immediately and staff (S1) did not ensure resident R1 was free of infliction of pain as staff S1 slapped R1 leaving a visable red mark on 7/25/2025 which poses/posed an immediate Health, Safety,or Personal Rights risk to persons
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(con't) 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Simranjit Rai
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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