435200989-12-20-2024-26-AS-KHOS-DFHR3J-20250407124000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200989
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:33:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20221102143338

FACILITY NAME:	BRIDGEPOINT AT LOS ALTOS		FACILITY NUMBER:	435200989
ADMINISTRATOR:	MARIA QUINTERO		FACILITY TYPE:	740
ADDRESS:	1174 LOS ALTOS AVENUE		TELEPHONE:	(650) 948-7337
CITY:	LOS ALTOS	STATE: CA	ZIP CODE:	94022
CAPACITY:	150	CENSUS: 121	DATE:	12/20/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Mehrad Moshiri		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident sustained multiple unexplained injuries while in care
Staff did not seek timely medical attention for resident
Staff dispensed wrong medication not prescribed to resident
Staff did not refill resident’s medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Mehrad Moshiri, Executive Director. On 11/02/2022, the Department received a complaint with the above allegations. On 11/09/2022, LPA Marrufo conducted an initial investigation. On 10/10/2024, LPA Marrufo conducted an additional complaint investigation visit.

On 09/13/2022, the facility submitted an LIC624 Unusual Incident/Injury Report (IR) to the Department. The IR states that on 09/07/2022, resident R1 had an unwitnessed fall in R1’s bathroom. Staff found R1 on R1’s left side. R1 was unable to answer staff questions and was slurring words when speaking. Staff called 911 immediately after finding R1 had fallen at 8:29 AM. Paramedics arrived onsite at 8:39 AM and transported R1 to the hospital for further evaluation.

See LIC9099-C for more information. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20221102143338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2024

NARRATIVE

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LPA Marrufo obtained a copy of R1’s Physician’s Report. The Physician’s Report states R1 can bathe himself/herself, able to dress/groom himself/herself, and able to care for his/her own toileting needs. The Physician’s Report states R1 is ambulatory.

LPA Marrufo obtained a copy of R1’s Care Plan, which has an effective date of 08/04/2022. R1’s Care Plan states R1 sleeps through the night usually and occasionally wakes up during the night to use the bathroom. R1’s Care Plan states R1 has no gait issues, completes all transfers independently, manages toileting independently, and has no history of falls. R1’s Care Plan does not make any mention of nightly or regular room checks.

LPA Marrufo obtained a copy of R1’s Care Tracking Log. The Care Tracking Log states that staff entered R1’s living unit on 09/06/2022 at 10:04 AM to provide routine medications, on 09/06/2022 at 1:13 PM to provide another routine medication, and at 09/06/2022 at 1:51 PM to provide R1 with a PRN medication. The entry on 09/06/2022 at 1:51 PM states R1 had been complaining of neck pain and the author of the entry will endorse to the PM medication technician to recheck the resident in an hour. The Care Tracking Log does not have an entry an hour after the entry on 09/06/2022 at 1:51 PM nor does it have any later entries on that day.
The Care Tracking Log entry on 09/07/2022 at 8:29 AM states R1’s medication technician called the author of the entry to R1’s apartment. R1 was found on the floor laying on R1’s left side and left arm in the middle of R1’s bedroom doorway. The author of the entry witnessed blood on the floor from a skin tear on R1’s left elbow. R1 was not responding to the staff’s questions about where R1 was, what year it was, and the name of a known family member. R1 was observed to be slurring words when speaking. Staff called 911 at 8:29 AM. The entry states that there was no witness to R1’s fall.

R1’s Care Tracking Log entries from 08/02/2022 until 09/07/2022 do not indicate any report of injuries or bruising visible on R1 besides R1’s reports of neck pain.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20221102143338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2024

NARRATIVE

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During visit on 11/09/2022, LPA Marrufo interviewed staff S1-S7 and Administrator Maria Quintero.

ADM stated that R1’s care plan did not include nightly checks or hourly checks.

S1-S7 stated to have never observed R1 with bruises prior to the fall incident.

R1’s Care Tracking Log entry from 07/22/2022 at 10:42 PM states staff advised R1 to press R1’s pendant if any help is needed.

During visit on 12/20/2024, Administrator Mehrad “Rod” Moshiri stated that staff provide a visual demonstration of how the emergency pendant is to be used when staff provide residents with an emergency pendant. Administrator Moshiri stated that staff instruct residents on how to turn on the pendant and turn it back off after it is used. Administrator Moshiri stated that staff recommend to residents to wear the pendant at all times.

During visit on 11/09/2022, LPA Marrufo interviewed staff S1-S7 and Administrator (ADM) Maria Quintero.

S1 stated to have entered R1’s bedroom to provide medications to R1 and observed R1 to be laying on the floor. S1 stated to have called 911 between 8:00 AM and 9:00 AM. S1 stated to have observed R1’s emergency pendant hanging by a chair near R1’s restroom and not hanging on R1’s person.

S1 stated to have not observed any medications not belonging to R1 in R1’s living unit. S1 stated that paramedics did not take any medications from R1’s living unit when they transported R1 to the hospital on 09/07/2022. S1 stated the facility policy is to provide a resident’s medication list and medication records to paramedics when paramedics come to transport a resident to the hospital. S1 stated to have provided paramedics with R1’s medication list and medication records, but not R1’s medications.

S3, S4, S5, S6, stated to not have observed any migraine or diarrhea medications in R1’s living unit. S7 stated to not be able to remember if there were any medications in R1’s living unit.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20221102143338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2024

NARRATIVE

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S2 stated to have not been onsite during the incident.

ADM stated that R1 had been put on medication management and all R1’s medications had been removed from R1’s living unit. ADM stated to have never observed any medications in R1’s living unit.

R1’s Care Plan states staff will assist with routine medications and PRN medications as directed.

During interview on 11/09/2022, S1 stated that R1’s pain patches for R1’s neck were ordered through the pharmacy, but the delivery of the pain patches had been delayed because R1’s insurance would not cover the costs of the pain patches and R1s doctor had not authorized a refill. S1 stated to have communicated with R1’s doctor about the pain patches. S1 stated R1’s family member contacted R1’s doctor to request authorization of the refill for the pain patches and finally decided to pay out of pocket for the pain patches.

During interview on 11/09/2022, ADM Quintero stated that staff were attempting to get the pain patch refilled by R1’s doctor and the pharmacy refused to refill the order because the pain patches were not covered by R1’s insurance.

LPA Marrufo obtained a copy of a fax communication sent to the pharmacy that supplied R1 with pain patches. The fax communication is dated 08/30/2022 and was sent by staff S1. The fax communication states, “Please refill all medications for this resident.” The resident named in the fax communication is R1. The fax communication includes a second page that is a list of R1’s Physician’s Orders, which includes R1’s pain patches.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Administrator Mehrad Moshiri and a copy of this report was provided.

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END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

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