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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801245
Report Date: 04/15/2024
Date Signed: 04/15/2024 05:16:01 PM

Document Has Been Signed on 04/15/2024 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BRISTOL HOMEFACILITY NUMBER:
486801245
ADMINISTRATOR/
DIRECTOR:		PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:1930 BRISTOL LANETELEPHONE:
(707) 373-6385
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:20 PM
MET WITH:Patricia BucalTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with House Manager Patricia Bucal.

This facility has a fire clearance for one non-ambulatory and three ambulatory residents. Areas toured were resident rooms and common areas. One resident room has a full private bathroom. No health and safety issues were observed. The backyard has a locked shed. Two staff and two resident records were reviewed.

A couple of topics were discussed.

The following shall be updated and submitted to CCLD by April 30, 2024:
-LIC 308 Designation of Administrative Responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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