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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200989
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:31:03 PM


Document Has Been Signed on 02/13/2024 04:31 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:MEHRAD MOSHIRIFACILITY TYPE:
740
ADDRESS:1174 LOS ALTOS AVENUETELEPHONE:
(650) 948-7337
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY:150CENSUS: 113DATE:
02/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rod MoshiriTIME COMPLETED:
04:45 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 address incident reports filed by the facility concerning medication errors, including an LIC624 Unusual Incident/Injury Report for an incident that occurred on 12/09/2022 and reported to the Department on 12/15/2022. The incident from 12/09/2022 involved a medication technician who gave another resident's morning medications to resident R1.

LPA Marrufo requests that the facility submit a Plan of Action to the Department by 02/20/2024 explaining how the facility will train staff and prevent medication errors.

An Advisory Note was issued. See LIC9102 for more information.

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: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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