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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 09/10/2021
Date Signed: 09/10/2021 11:58:40 AM

Document Has Been Signed on 09/10/2021 11:58 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BRISTOLWOOD HOMEFACILITY NUMBER:
435202404
ADMINISTRATOR:NOEL DIZONFACILITY TYPE:
740
ADDRESS:2194 BRISTOLWOOD LANETELEPHONE:
(408) 946-4454
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 3DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Noel DizonTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Noel Dizon.

During visit, LPA observed the inside and outside of the faciilty. LPA observed the facility kitchen and food storage areas and observed there to be a 7-day supply of non-perishable foods and a 3-day supply of perishable foods. LPA toured 3 out of 3 resident bedrooms and 2 out of 2 resident bathrooms. The bathrooms had signs posted promoting hand washing and sanitation. The outdoor area was free of obstructions along the exits.

LPA observed that the facility did not have a visitor screening area to log temperatures and record responses to symptom screening questions. LPA observed that the facility only had 1 N95 mask. The facility did have a supply of surgical masks and gloves. LPA observed that the facility has not submitted a completed LIC808 Mitigation Plan.

Advisory Notes were issued - see LIC9102s for more information.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Noel Dizon and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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