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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 04/11/2024
Date Signed: 04/11/2024 10:15:15 AM

Document Has Been Signed on 04/11/2024 10:15 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BRISTOLWOOD HOMEFACILITY NUMBER:
435202404
ADMINISTRATOR/
DIRECTOR:		LAGMAN, DONNAFACILITY TYPE:
740
ADDRESS:2194 BRISTOLWOOD LANETELEPHONE:
(408) 946-4454
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Donna LagmanTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) conducted an unannounced case management visit following up on the visit conducted on 12/28/2023. LPA met with Administrator, Donna Lagman and stated the purpose of the visit.

On 12/27/2023, the Department received an Incident Report from the facility stating resident (R1) had a fall in his/her bedroom and was transported to the hospital via 911. On 12/26/2023 at approximately 3am, R1 fell in the bedroom and rang the bell for assistance. R1 was taken to the hospital at approximately 9:05am and kept in the Intensive Care Unit (ICU) to monitor breathing and pain.

On 12/28/2023, LPA conducted a visit and interviewed 3 staff and requested documentation. Based on the interviews conducted, 3 out of 3 staff stated the facility staff did not seek medical attention right away once R1 expressed pain was uncontrollable at approximately 7am and wanted to go to the hospital. Based on review of phone calls made between S1 and Administrator. S1 stated he/she needs to ask Administrator for permission to call 911 for residents. S1 stated Administrator will make the decision to call 911. At approximately 7:49am & 7:55am, Administrator called and left a voicemail to R1’s responsible party to take R1 to the hospital. At 8:53am, the Administrator texted S1 to call 911 and seek medical attention. The paramedics arrived at the facilty and transported the resident to the hospital at approximately 9:05am.

Based on interview with S1 and S2, S2 admitted to sleeping during his/her shift as the awake night staff on 12/26/2023 and did not hear R1’s calling for help. S1 stated he/she was not working and was sleeping when he/she heard R1’s bell ringing. S1 stated he/she woke up S2 to check on R1. R1 had refused to go to the hospital at that time and requested PRN pain management medication. At around 7am, S1 stated that R1 was complaining of pain and S1 tried to contact R1’s responsible party and he/she did not pick up. Based on review of R1's LIC 602A Physician's Report dated 2/13/2023, the resident has diagnosis of Dementia.
Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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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: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404
VISIT DATE: 04/11/2024
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On 1/5/2024, R1 passed away at the hospital. Based on review of the Death Report, the cause of death was complications of rib fractures and unwitnessed fall.

Deficiencies were cited per California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalties for the violation resulting in serious bodily injury is pending for further review.

This report was reviewed with Administrator, Donna Lagman and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2024 10:15 AM - It Cannot Be Edited


Created By: Simranjit Rai On 04/05/2024 at 08:21 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
87465(a)(1)

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87465 Incidental Medical and Dental Care (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure staff are trained to seek timely medical attention by POC due date. Administrator agreed and understood.
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Based on interview and record review, facility staff delayed seeking medical attention for R1 after having a fall at 3am and was in pain &was transported to the hospital at 9:05am which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
04/12/2024
Section Cited
CCR87468.2(a)(4)

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87468.2(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and schedule in-service staff training by POC due date. Administrator agreed and understood.
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Based on interview,on-call night staff did not respond to R1's call for help; off-duty staff heard and prompted to assist R1 which poses/posed an immediate Health, Safety, or Personal Rights risk to persons 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024


LIC809 (FAS) - (06/04)
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