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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202011
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:43:41 AM

Document Has Been Signed on 02/17/2022 11:43 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HEARTS AND MINDS ACTIVITY CENTERFACILITY NUMBER:
435202011
ADMINISTRATOR:MARIA NICOLACOUDISFACILITY TYPE:
775
ADDRESS:2380 ENBORG LANETELEPHONE:
(408) 279-7515
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 90CENSUS: DATE:
02/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:MARIA NICOLACOUDISTIME COMPLETED:
11:50 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management visit and met with Administrator (ADM) Maria Nicolacoudis. The purpose of the visit was to inspect the building expansion on 2300 Enborg Lane.

The facility has an approved fire clearance for 150 non-ambulatory clients. There are no clients observed on site. Facility sketch and exit routes are posted throughout facility.

LPA toured the facility inside and outside to include the entry point, activity space, kitchen, classrooms, bathrooms, hallway, office, and patio area. Classrooms were equipped were proper furniture and lighting. Bathrooms contains paper supplies, hygiene products, and grab bars. Hot water temperature was maintained at 119.6 degrees Fahrenheit. Internal temperature was maintained at 65 degrees Fahrenheit. ADM is aware to maintain an internal temperature of 68 degrees to 85 degrees once space is being used by clients. Facility has a separate room for use of ill clients.

Facility is equipped with smoke detectors and fire extinguishers. Facility is not equipped with a carbon monoxide detector. ADM is aware to purchase carbon monoxide detector(s) prior to clients using the new expansion. Hallway and exit routes were free and clear of obstruction.

LPA observed the building expansion is ready to be used.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Maria Nicolacoudis and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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