435200989-10-10-2024-26-AS-KJAN-D9WU5N-20241010151701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200989
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:17:11 PM

Document Has Been Signed on 10/10/2024 03:17 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:	BRIDGEPOINT AT LOS ALTOS		FACILITY NUMBER:	435200989
ADMINISTRATOR:	MEHRAD MOSHIRI		FACILITY TYPE:	740
ADDRESS:	1174 LOS ALTOS AVENUE		TELEPHONE:	(650) 948-7337
CITY:	LOS ALTOS	STATE: CA	ZIP CODE:	94022
CAPACITY:	150	CENSUS: 117	DATE:	10/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mehrad Moshiri and Maria Quintero		TIME COMPLETED:	03:30 PM

NARRATIVE

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On October 10, 2024, Licensing Program Analysts (LPAs) Kiran Jain and David Marrufo arrived at the facility at 09:00 AM to conduct the Annual 1-year required inspection. LPAs met with Maria Quintero, Assistant Executive Director and Rod Moshiri, Executive Director, and explained the purpose of the visit.

The facility currently has residents in Assisted Living and Independent Living. LPAs conducted a tour in the presence of a staff member of the physical plant, including common areas, dining rooms, resident bedrooms, bathrooms, kitchen, and outdoor spaces.

All exits, common areas, and outdoor areas were observed to be clear and free from obstructions. The fire extinguishers were fully charged and last serviced on 10/08/2024. The facility’s emergency disaster plan was reviewed. No accessible bodies of water or hazards were observed. The smoke detectors were last tested on 09/26/2024. LPAs tested two carbon monoxide detectors during the visit and both were fully operational.

LPAs inspected 12 residents’ rooms and 12 bathrooms at random. Rooms were observed to have the required furniture and sufficient lighting. Emergency pull cords were tested in rooms and staff arrived between 4 to 10 minutes. The hot water temperature was measured in the residents’ bathrooms between 106.7°F and 118.9°F.

LPAs observed the dining room and the main kitchen. The kitchen was observed to have the required 7 days of non-perishables and 2 days of perishable food. LPAs toured the walk-in refrigerator and freezer, and pantry for the dry food. No expired food items were observed and open food items were wrapped.

The First Aid kit was checked and observed to be complete. Emergency drills are conducted quarterly with the last drill documented on 08/20/2024.

See LIC 809-C for more information. Page 1 of 2.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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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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: BRIDGEPOINT AT LOS ALTOS	FACILITY NUMBER: 435200989
	VISIT DATE: 10/10/2024

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LPAs reviewed five resident records. All were observed to be complete. The resident’s medications are securely stored in a locked medication room. Centrally Stored Medication Logs were reviewed for 5 residents and found them to be complete.

At 12:48 PM, LPAs reviewed 5 personnel records. 2 out of 5 reviewed staff records for S1 and S2, did not contain a current First Aid certificate, which poses a potential safety risk to persons in care.

The following updated forms are requested to be submitted to CCLD by 10/17/2024:

· LIC 500: Personnel Report
· LIC 308: Designation of Facility Responsibility
· Certificate of Liability Insurance

A deficiency was cited under the California Code of Regulations, Title 22. Failure to correct the deficiency by the due date may result in civil penalties. See LIC 809-D page for more information.

This report was reviewed with Rod Moshiri, Executive Director and a copy of this report along with appeal rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 10/10/2024 03:17 PM - It Cannot Be Edited

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: BRIDGEPOINT AT LOS ALTOS	FACILITY NUMBER: 435200989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 2 out of 5 reviewed staff records for S1 and S2 did not contain a current First Aid certificate, which poses a potential safety risk to persons in care.
	POC Due Date: 10/17/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agrees to submit a copy of current First Aid ceritifcates for S1 and S2 by the POC due date of 10/17/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

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