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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200989
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:08:14 PM


Document Has Been Signed on 01/12/2023 01:08 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 ALTOSFACILITY NUMBER:
435200989
ADMINISTRATOR:MARIA QUINTEROFACILITY TYPE:
740
ADDRESS:1174 LOS ALTOS AVENUETELEPHONE:
(650) 948-7337
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY:150CENSUS: 120DATE:
01/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rod MoshiriTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Rod Moshiri. The purpose of the visit was to obtain documents in regards to an incident that occurred on 01/07/2023 and was self-reported by the facility.

During visit, LPA Marrufo obtained copies of R1's Physician's Report, Assessment, and Progress Notes.

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

This report was reviewed with Administrator Rod Moshiri and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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