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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202404
Report Date: 07/25/2024
Date Signed: 07/25/2024 07:05:09 PM

Document Has Been Signed on 07/25/2024 07:05 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:
07/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lead Staff, Irish Samantha SinioTIME VISIT/
INSPECTION COMPLETED:
07:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced continuation of the annual visit and met with Lead Staff, Irish Samantha Sinio. LPA Rai spoke with Licensee (LIC) Cindy Chen and Administrator (ADM) Donna Lagman and stated the purpose of today's visit. Both LIC and ADM informed LPA Rai over the phone they will not be present at the facility during todays visit. LPA Rai observed 4 staff, including Lead Staff and 4 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed three locked storage unit which was used as storage and not habitual space. LPA Rai observed the laundry machine in the backyard and observed 2 laundry detergents and 5 gallons of paint unlocked and accessible to the residents Lead Staff removed the items and locked them in one of the storage units. LPA Rai observed 1 resident smoking in the backyard who has neurocognitive disorder and was not supervised. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies.

LPA Rai toured 6 bedrooms, out of which 4 bedrooms are occupied by residents and 2 bedrooms are occupied by staff. The resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai observed 2 out of 4 resident had half-bed rails attached to the resident's bed. Lead Staff stated the residents do not have signed written physician's order for residents to use half-bed rails for mobility. Lead Staff confirmed the 2 residents are not under Hospice or Home Health services.

LPA Rai toured the garage and observed a sofa with blankets and rack of cloths hanging over the soda. Lead Staff states the bed is for lounging for staff and the garage is not used as a bedroom for any person.

Continuation on LIC 809-C, Page 1 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/25/2024 at 05:16 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.
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 medication refills are obtained in a timely manner by POC due date. Administrator agreed and understood.
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Based on record review and interview, the facility staff did not have R1's medication #1 refill at the facility during the time of inspection and medication was to be administered at bedtime which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
07/26/2024
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) ...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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 toxic substanced are inaccessible to resident by POC due date. Administrator agreed and understood.
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Based on observation and interview, 2 laundry detergent containers and 5 containters of paint were located near the laundry mahcine in the backyard accessible to residents 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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/25/2024 at 05:26 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.
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 resident's room and bathroom are clean and sanitary and in good repair by POC due date. Administrator agreed and understood.
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Based on observation and record review, bathroom in resident room #5 had yellow stains on the toliet seat/bowel and dark brown/black stains on the floor near the base of the toliet which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
07/26/2024
Section Cited
CCR87465(h)(6)

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87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...
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 in-service training is provided for medication administrator and accurate record keeping by POC due date. Administrator agreed and understood.
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Based on record review, observation and interview, 4 out of 4 resident files did not contain Centrally Stored Medication Log/Record 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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/25/2024 at 05:34 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
HSC
15655

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W&IC 15655 (a)(1) long-term care facilities, ... shall provide to all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights as specified in Section 15633.
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 review and sign SOC 341A by POC due date. Administrator agreed and understood.
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Based on record review and interview, 2 out of 2 staff files reviewed did not contain signed copy of the SOC341 and ADM was not aware of regulation which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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During visit on 7/12/2024, ADM provided SOC341A to S1 and S2 and obtained signed copies for staff file.
Type A
07/26/2024
Section Cited
CCR87411(a)

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be... competent to provide the services necessary to meet resident 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 will ensure staff receive in-service training on medication managment and administration where staff will ensure recordkeeping is accurate by POC due date. Administrator agreed and understood.
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Based on record review and interview, R1's medication #1 was not refilled and not located at the facility and R1's medication #1 order is to be administered at bedtime 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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/25/2024 at 05:43 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87405(d)(1-7)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement is not met as evidenced by:
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Administrator stated to follow up with Licensee and submit a written plan of action understanding regulation and and a plan on obtaining training on Title 22 regulations by POC due date. Administrator agreed and understood.
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Based on record review, interview, and observation, ADM did not ensure resident medication was available to administer and medicaton log was not completed, chemicals were accessible to residents with Dementia, resident room/bedrooms are not in sanitary conditions, fire drills are not conducted every
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(con't) quarter, residents using half bed rails for mobility, without signed written physician's order, staff are not coptentent to provide medication administration to residents, 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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 07/25/2024 07:05 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/25/2024 at 06:00 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRISTOLWOOD HOME
FACILITY NUMBER: 435202404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2024
Section Cited
CCR
87608(a)(3)

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87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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 signed written order from physician is obtained when half-bed rails is used for mobility by POC due date. Administrator agreed and understood.
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Based on record review, obserbation and interview, 2 out of 4 residents using half-bed rails for mobility did not have signed written physician's order in resident's file which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
08/01/2024
Section Cited
HSC1569.695(c)

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1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios.
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 disaster drill is conducted at least quartely by POC due date. Administrator agreed and understood.
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Based on record review and interview, the ADM conducted last disaster drill on 1/2/2024 which poses/posed a potential 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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


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: 07/25/2024
NARRATIVE
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Page 2 of 3.

LPA Rai observed 3 facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.4 degrees F - 111.4 degrees F. LPA Rai observed the third bathroom located in resident room #5 was not disclosed on the facility sketch. LPA Rai spoke with ADM and LIC regarding the third bathroom in resident room #5 and they both stated the bathroom has been part of the facility since the facility received the license and the facility had not made modification to the physical plant since obtaining the license. LIC stated she will reach out to the City of San Jose and send an updated Facility Sketch to the Department.

LPA Rai observed yellow stains on the toilet seat and toilet bowl in the bathroom located in resident room #5.LPA Rai observed dark brown/black stains on the floor near the base of the toilet. LPA Rai observed resident occupying resident room #5 smoking in the backyard. LPA Rai asked Lead Staff regarding the yellow and dark brown/black stains and Lead Staff stated they attempted to clean the stains in the past but were not successful.

Fire extinguisher was observed and inspected on 01/05/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. Per review of the records, the last disaster drill was conducted on 01/24/2024 Lead Staff confirmed the facility ADM did not conduct a disaster drill after 01/24/2024. LPA Rai discussed disaster needs to be conducted quarterly according to Title 22 regulations.

LPA Rai reviewed resident medications and central stored medication records. LPA Rai reviewed R1's medication with Lead Staff. During observation of R1's medication to R1's Medication Administration Record (MAR), Lead Staff noticed R1's medication #1 did not have medication tablets in the medication bottle. Lead Staff stated they did not refill medication #1 and medication was not available at the facility. During visit, LPA Rai informed Lead Staff to contact the pharmacy to ensure resident's medication is available for pick up. Lead Staff stated to pick up medication on resident's behalf.

During review of resident's Centrally Stored Medication Log/Record for all 5 residents and Lead Staff stated to misplaced the documents.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: 07/25/2024
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Page 3 of 3.
During previous visit on 7/12/2024, LPA Rai reviewed staff records, LPA Rai observed the staff records did not contain SOC 341A Statement Acknowledging Requirement To Report Suspected Abuse of Dependent Adults and Elders. ADM was present during visit on 7/12/2024 and when asked, ADM stated "was not aware about the staff signing the document". LPA Rai referred ADM to W&IC 15655 wherein the facility shall provide to all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights. ADM stated agreed and understood.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs, such as administer medication to residents in care. During audit of the medication, R1 did not have medication which is required to be administered today during bedtime and Lead Staff stated medication can be picked up tomorrow, indicating the medication will be missed today due to medication not available at the facility. After LPA Rai discussed the importance of following physician's orders and

During visit, LPA Rai spoke with Licensee/Corporation's President & Secretary (LIC) Cindy Song Chen and Administrator/Corporation's Treasurer (ADM) Donna Lagman. Both LIC and ADM were not available to be present at the facility and informed LPA Rai of the same during telephone conversation. In order to exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves, as discussed in the past, both Licensee and Administrator have to be available and present at the facility 20 hours a week, Monday through Friday 8:00am - 5:00pm. LIC and ADM to submit an updated LIC 500 to reflect the hours of both individuals present at the facility during Monday - Friday.

Deficiencies were cited per California Code of Regulations, Title 22 during today's visit, please see LIC 809-D.
Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Lead Staff, Irish Samantha Sinio and a copy of the report was provided. LPA Rai reviewed this report over the phone with Administrator, Donna Lagman. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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