435202011-12-17-2025-26-AS-CCHG-DPFVZ3-20251217155205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202011
Report Date: 12/17/2025
Date Signed: 12/17/2025 03:52:10 PM

Document Has Been Signed on 12/17/2025 03:52 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 CENTER		FACILITY NUMBER:	435202011
ADMINISTRATOR/ DIRECTOR:	MARIA NICOLACOUDIS		FACILITY TYPE:	775
ADDRESS:	2380 ENBORG LANE		TELEPHONE:	(408) 279-7515
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 150		CENSUS: 94	DATE:	12/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Maria Nicolacoudis		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Steve Chang conducted an Annual inspection visit and met with the CEO, Maria Nicolacoudis.

LPA reviewed 5 client file and 5 staff files.

LPA toured the facility inside and out. Room temperature was observed at 72 degree F. Hot water temperature was observed at 112 degree F. LPA inspected 3 activities rooms in the main building – Diamond room, Emerald room, and Ruby room. Clients were observed engaged in activities with staff. Medication room was observed locked. Kitchen was observed locked. Housekeeping storage room was observed locked. Laundry room was observed locked. The temperature of the refrigerator was observed at 40 degree F and the temperature of the freezer was observed at 0 degree F. Fire extinguisher was serviced on 3/17/2025.

LPA inspected the new section/building LPA inspected Program Rooms #1 and #2, computer room, conference room, library room and office. LPA inspected outdoor patio area, 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. A storage room was observed at outdoor area.

The bathrooms were observed to be clean and equipped with trash cans, grab bars, liquid soap, and paper towels. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested, and were working fine.

The last time the facility conducted the fire drill was on 12/04/2025.

No citation noted today. Exit interview was conducted with CEO. This report was provided to CEO for signature. A copy of the report was provided to CEO.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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