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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801245
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:04:12 PM

Document Has Been Signed on 04/19/2022 02:04 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BRISTOL HOMEFACILITY NUMBER:
486801245
ADMINISTRATOR:PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:1930 BRISTOL LANETELEPHONE:
(707) 373-6385
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Charisma Mari, House ManagerTIME COMPLETED:
01:16 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and was greeted by staff live-in staff Edguardo and Aida. House Manager Charisma Mari arrived later. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA conducted a walk-through of the facility and observed 2 of 4 clients in care; the other clients 2 were at day program. Facility has a screening station with sign-in sheet and COVID questionnaire. Staff took LPA's temperature upon arrival. Staff have CPR/first aid certifications. Fire extinguisher was charged.
The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff have received training on the following topics: infection prevention, symptoms, transmission and PPE use. Staff and client's temperatures are taken daily and documented. House Manager stated staff clean and disinfect the facility throughout the day. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.
LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms.

LPA discussed the following requirements with House Manager:
· Obtain N-95 mask fit testing for staff (Cal/OSHA requirement).
· Documenting COVID-19 staff training on infection prevention, symptoms, transmission and PPE use.
· Staff must wear face masks in the facility regardless of vaccination status.
· Have fire extinguisher serviced and tagged by the Fire Department
report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BRISTOL HOME
FACILITY NUMBER: 486801245
VISIT DATE: 04/19/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 5/9/2022
    · LIC 308 Designation of Facility Responsibility
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources
    · LIC 402 Surety Bond
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility Clients
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

    Exit interview conducted with House Manager, whose signature on this document confirms receipt.

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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