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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200873
Report Date: 06/23/2023
Date Signed: 06/23/2023 12:44:52 PM


Document Has Been Signed on 06/23/2023 12:44 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:KNOX, KATHLEEN LFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: DATE:
06/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:David Ayala, Resident Care Director TIME COMPLETED:
01:10 PM
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 On this day at around 11:50 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct case management visit in connection with a suicide incident that occurred at the facility. LPA met with Resident Care Director (RCD) David Ayala and explained the purpose of visit.

LPA obtained the following records for Resident 1 (R1):

1. Physician's Report
2. Preplacement Appraisal
3. Admission's Agreement
4. Psychiatric Evaluation
5. Service Plan
6. Emergency Information
7. Letter

A referral to Investigations Branch (IB) has been made.

LPA advised RCD to send all incident/death reports to CCL via fax at 510-286-4204 or email to CCLASCPOaklandRO@dss.ca.gov and not to send to any LPA email address.

A copy of this report was provided to RCD.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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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