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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 07/12/2024
Date Signed: 07/12/2024 04:52:14 PM

Document Has Been Signed on 07/12/2024 04:52 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
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:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Administrator, Donna LagmanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted a 1-Year Required annual inspection visit. LPA Rai met with Staff (S3) Pamela Sinio. S3 stated 3 residents were at the facility and 1 resident was out of the facility. Administrator, Donna Lagman arrived to the facility during the visit.

During visit, LPA Rai reviewed 2 resident files and 2 staff files.

LPA Rai interviewed 2 staff (S1-S2) and ADM pertaining to the Case Management conducted on 12/28/2023. LPA Rai wanted to clarify information provided during the visit and obtain additional documents to include but not limited to R1's Appraisal/Needs and Services Plan.

LPA Rai obtained a copy of current LIC 500, which was updated 1/1/2024. ADM stated the facility night shift (10pm - 6am) is on-call shift and will not be reflected on the LIC 500. ADM stated their Program Plan for staff working night shift (10pm-6am) is on call and the facility does not have awake night staff.

LPA Rai will return another day to complete annual inspection. This report was reviewed with Administrator, Donna Lagman and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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