486801245-4-11-2023-21-AS-VBEI-CQSSZH-20230411141909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801245
Report Date: 04/11/2023
Date Signed: 04/11/2023 02:19:21 PM

Document Has Been Signed on 04/11/2023 02:19 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BRISTOL HOME		FACILITY NUMBER:	486801245
ADMINISTRATOR:	PUNZALAN, ELPIDIO		FACILITY TYPE:	735
ADDRESS:	1930 BRISTOL LANE		TELEPHONE:	(707) 373-6385
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4		CENSUS: 4	DATE:	04/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Backup Administrator Virginia Punzalan		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Backup Administrator Virginia Punzalan arrived later. LPA initiated a tour of the facility around 11:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 130 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. LPA observed a cabinet that was locked that had coffee and and other non-perishable foods along with knives. LPA questioned why the food was locked and staff explained that it is locked due to the behavior of a client. LPA and staff discussed alternative ways to address the behavior including, but not limited to, requesting a waiver to lock food and what would be required if facility chose to continue locking the cabinet. LPA confirmed that facility is not locking the refrigerator and that they provide meals and snacks per regulation. Medications were centrally stored and locked. Fire extinguisher was last inspected May 2022. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted September 10, 2022. LPA notified staff that the requirement is now a Disaster Drill/Emergency Drill each quarter. Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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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Document Has Been Signed on 04/11/2023 02:19 PM - It Cannot Be Edited

Created By: Victoria Bertozzi On 04/11/2023 at 01:31 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BRISTOL HOME	FACILITY NUMBER: 486801245
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by water temperature in resident bathroom reading at 130F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2023
	Plan of Correction
1 2 3 4	Facility immediately turned down water heater. Deficiency is cleared. Facility will continue to monitor water until it is within regulation and submit a picture showing water within regulation to LPA by 4/12/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Hope DeBenedetti

LICENSING EVALUATOR NAME:

Victoria Bertozzi

LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BRISTOL HOME	FACILITY NUMBER: 486801245
	VISIT DATE: 04/11/2023

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Continued from LIC809

Three staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Elpidio Punzalan, 6007496735 expired 2/1/2023 but is on the pending list. Medications and medication records were reviewed. Client P&I was also reviewed.

Back-upAdministrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit updates of the following documents by 4/21/2023:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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