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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200989
Report Date: 06/01/2021
Date Signed: 06/01/2021 03:09:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:BRIDGEPOINT AT LOS ALTOSFACILITY NUMBER:
435200989
ADMINISTRATOR:MARIA QUINTEROFACILITY TYPE:
740
ADDRESS:1174 LOS ALTOS AVENUETELEPHONE:
(650) 948-7337
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY:150CENSUS: 98DATE:
06/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Maria QuinteroTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) David Marrufo and Ryker Heberle conducted an unannounced Case Management visit and met with Administrator Maria Quintero. The purpose of the visit was to inquire about a death that occurred at the facility. The facility submitted a death report for the incident on 05/28/2021.

During visit, LPAs Marrufo and Heberle interviewed Administrator Quintero. LPAs obtained the following documents for resident R1, the resident who was reported to have died in the death report: Physician's Report and Service Plan.

LPAs requested copies of the police report and coroner report once they are available.

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

This report was reviewed with Maria Quintero and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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