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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200989
Report Date: 03/28/2024
Date Signed: 03/28/2024 11:02:43 AM


Document Has Been Signed on 03/28/2024 11:02 AM - 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: DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
11:00 AM
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 On 3/28/2024, at approximately 9:30 a.m. Licensing Program Analysts (LPAs) Maria (Mita) Partoza a case management visit in regards to an incident report involving a resident and met with Executive Rod Moshiri. LPA stated the purpose of the visit. LPA conducted a file review and requested copies of the resident's file including but not limited to admission agreement, medication list and physician's report.

No deficiency cited at today's visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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