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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200989
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:05:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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: 103DATE:
08/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jayden BettencourtTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Jayden Bettencourt, Wellness Director.

On 05/28/2021, the Department received a death report from the facility regarding resident R1’s death from self-inflicted gunshot wound. The Department conducted an investigation of neglect and lack of supervision resulting in R1’s death from a self-inflicted gunshot wound. The Department interviewed 6 facility staff and 1 resident and reviewed records.

Interviewed staff stated resident R1 always appeared cordial with care staff, did not complain, and did not show any indication that R1 was depressed or wanted to commit suicide. R1 did not require multiple checks in a day. R1 preferred to stay in R1’s room, and staff encouraged R1 to come out of R1’s room and join activities.

Needs and Services Plan and physician’s report were reviewed. Needs and Services Plan dated 03/20/2021 indicated R1 does not need safety checks. Physician’s report dated 08/11/2017 indicated R1 does not have any suicidal behavior.

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

Based on the Department’s investigation through interviews and record reviews, the Department has found that the investigation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Jayden Bettencourt 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: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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