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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202011
Report Date: 12/06/2024
Date Signed: 12/06/2024 03:50:49 PM

Document Has Been Signed on 12/06/2024 03:50 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:HEARTS AND MINDS ACTIVITY CENTERFACILITY NUMBER:
435202011
ADMINISTRATOR/
DIRECTOR:		MARIA NICOLACOUDISFACILITY TYPE:
775
ADDRESS:2380 ENBORG LANETELEPHONE:
(408) 279-7515
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 150CENSUS: 58DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Maria Nicolacoudis, CEOTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On December 06, 2024, at 1:45 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the CEO, Maria Nicolacoudis and disclosed the purpose of the inspection.

LPA toured the physical plant and observed it to be clean and odor-free at a comfortable temperature and adequate lighting. LPA inspected 3 activities rooms in the main building – Diamond room, Emerald room, and Ruby room. Clients were observed engaged in activities, playing dart, bingo games, and craft activities, and exercising. LPA inspected the new section/building added recently for higher functioning clients and observed clients participating in Christmas Carol Bingo in Craft café room. LPA inspected Program Rooms #1 and #2, technical center, and the laundry room. No obstructions were observed in the hallways.

LPA inspected outdoor patio area next to Emerald room, and observed outdoor table, chairs, and umbrellas for clients’ use and garden beds for gardening activities. No accessible bodies of water or fire safety/tripping hazards were observed.

LPA inspected the kitchen and observed sharp objects and cleaning supplies were stored/locked properly and inaccessible to the clients. No cooking was observed. The CEO mentioned that staff prepares snacks for the clients and lunch is catered through IL Pastaio Food and is served once it is brought. LPA inspected the refrigerator and observed milk, cheese, fresh vegetables, and fruits stored.

The bathrooms were observed to be clean and equipped with trash cans, grab bars, liquid soap, and paper towels. The hot water temperature was measured in (2) bathrooms at 109.4°F and 108.7°F.

The client’s medications were securely stored in a locked Med room. Medications were organized in separate bins for each client. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) and Medication Administration Record (MAR) were reviewed and found to be complete. LPA inspected the first aid kit and observed it fully stocked.

Continued on LIC 809-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: HEARTS AND MINDS ACTIVITY CENTER
FACILITY NUMBER: 435202011
VISIT DATE: 12/06/2024
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LPA reviewed 5 random client files and 5 random staff files. The LPA observed that 5 of 5 clients had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan. LPA observed that 5 of 5 staff members had First Aid/CPR training, LIC 508 Criminal Record Statements and Health Screening and confirmed that 5 of 5 staff members are associated with the facility.

Fire extinguishers were observed fully charged and last serviced on 03/25/2024. Smoke detectors with sprinklers were observed. The CEO tested the carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. The First Aid kit was checked and observed to be complete. LPA reviewed Emergency Drill Logs and observed drills are conducted quarterly, with the most recent drill completed on 08/07/2024.

The following updated forms are requested to be submitted to CCLD by 12/13/2024:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Administrator Certificate(s)

No deficiencies were cited during today's visit.

An exit interview was conducted. A copy of this report was left with the CEO, Maria Nicolacoudis, whose signature on this form confirms receipt of the report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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