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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707358
Report Date: 10/06/2023
Date Signed: 10/06/2023 05:00:56 PM

Document Has Been Signed on 10/06/2023 05:00 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:LA CASA DEL PUENTEFACILITY NUMBER:
430707358
ADMINISTRATOR:JENNIFER NGUYENFACILITY TYPE:
772
ADDRESS:17415 & 17425 DEPOT STREETTELEPHONE:
(408) 778-0555
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 12CENSUS: 12DATE:
10/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Matthew MiaoTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Program Director, Matthew Miao. The purpose of the visit is to follow-up on an incident report the Department has received regarding a medication error at the facility that occurred on 08/05/2023.

During visit, LPA was informed that the client (C1) was residing at another facility and the medication error was not conducted at this facility. The review of records show C1 was not residing in the facility during the time of the incident.

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

This report was reviewed with Program Director, Matthew Miao and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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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