435202154-8-22-2024-26-AS-RMAO-D8QMGW-20240902093633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202154
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:16:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/16/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240716174157

FACILITY NAME:	MISSION BAY, INC.		FACILITY NUMBER:	435202154
ADMINISTRATOR:	MARIA COKER		FACILITY TYPE:	775
ADDRESS:	980 RINCON CIR.		TELEPHONE:	(408) 433-3303
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	135	CENSUS: 54	DATE:	08/22/2024
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Program Director Raul Regencia		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/Lack of Supervision resulted in resident injury

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Program Director Raul Regencia .

On July 16, 2024, the Department received a complaint alleging Neglect/Lack of Supervision resulted in resident injury. It has been alleged that client C1 sustained a bite mark and bruises on July 2, 2024, while attending the day program.

On July 26, August 13 and 22, 2024, LPA Monter interviewed Clients C1-C6. 3 Out of 6 Clients interviewed (C3, C4, C5) stated they did not see any client bite or hit C1 and did not see C1 bit him/herself. Client C1 stated he/she was not bitten by a client and denied biting or hitting him/herself. Client C2 and C6 did not respond to LPA’s questions, and was unable to provide answer due to developmental disability.

Page 1 Out of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20240716174157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MISSION BAY, INC.	FACILITY NUMBER: 435202154
	VISIT DATE: 08/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On July 26 and August 13, 2024, LPA Monter interviewed staff S1-S6. Staff S1, S2 and S3 stated on July 2, 2024, C1 was having an behavior inside the van, in the parking lot of the Milpitas library. S1, S2 and S3 stated C1 was having behavior like throwing shoes and grabbing him/herself. S1 stated he did see the red mark on C1’s arm and believed it came from the tantrum.

6 Out of 6 staff interviewed stated they did not see Client C1 hit/bite him/herself. 6 Out of 6 staff interviewed stated they did not see other clients hit/bite C1. 4 Out of 6 staff interviewed stated C1 does hit him/herself when upset/ during a tantrum.

Based on record review, Client C1 attends a different Mission Bay Adult day program in the morning. (220 South Main St. Client). C1 attends Mission Bay (980 Rincon Circle) in the afternoon.

On August 22, 2024 LPA Monter conducted a collateral visit at Mission Bay (220 South Main St.) Based on record review, client C1 is group in with clients C7 and C8. LPA attempted to interview C7 but C7 did not respond to LPA’s questions, and was unable to provide answer due to developmental disability. Client C8 is on vacation and could not be interviewed.

LPA interviewed 5 staff, S7-S11. 5 Out of 5 staff interviewed stated they have not observed C1 bite him/herself. 5 Out of 5 staff interviewed stated they did not observe any clients hit or bite C1. 4 Out of 5 staff interviewed stated C1 has a self injurious behavior wherein C1 will hit him/herself.

Based on a review of C1’s Individual Program Plan (IPP) dated March 29, 2024, C1 has episodes of hitting, pushing, throwing shoes and grabbing others.

Based on a review of Facility Special Incident Report, dated July 9, 2024 states on July 2, 2024 C1 displayed unexpected aggressive behavior. C1 threw his/her shoes at a staff member and attempted to grab staff. C1 also grabbed his/her own arms, causing red marks on his/her left arm. The incident report states an ice pack was applied to the affected area, which helped the redness subside.

Page 2 Out of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240716174157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MISSION BAY, INC.	FACILITY NUMBER: 435202154
	VISIT DATE: 08/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On August 21, 2024, LPA Monter interviewed C1’s Responsible Party (C1RP). C1RP stated C1 did not have any self injurious behaviors on July 2, 2024, before going to day program that day.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation that C1 had sustain a bruises and a bite mark is factually true, there is not a preponderance of evidence to prove nor disprove that client C1 had sustained injuries from neglect/lack of supervision.

Page 3 Out of 3.

END OF REPORT.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3