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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202154
Report Date: 04/16/2025
Date Signed: 04/16/2025 08:57:05 AM

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
01/03/2025 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20250103145337
FACILITY NAME:MISSION BAY, INC.FACILITY NUMBER:
435202154
ADMINISTRATOR:MARIA COKERFACILITY TYPE:
775
ADDRESS:980 RINCON CIR.TELEPHONE:
(408) 433-3303
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY:135CENSUS: 126DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Raul Santos TIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Client sustained multiple unexplained injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Program Director (PD) Raul Regencia.

On 01/03/2025, the Department received the complaint. On 01/06/2025, the initial complaint investigation was conducted. Documents were obtained to include: client roster, client/staff groupings, LIC500, and 4 resident files to include: physician's report, IPP, incident reports, fire department report, and emergency form.

It was alleged that on 12/30/2025, client (C1) sustained multiple unexplained injuries while in care of the day program. It was alleged that C1 sustained a seizure without staff noticing and collapsed which may have resulted in C1 sustaining multiple fractures. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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-20250103145337
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: 04/16/2025
NARRATIVE
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Throughout the investigation, 4 staff members were interviewed. Based on staff interview, it was stated that a staff had called for help after he/she observed C1 had passed out in his/her chair while playing on his/her tablet. Staff called 911 and C1’s responsible party.

The staff who observed the incident stated that he/she thought C1 had a seizure because C1 was drooling, however, denied the observation of C1 displaying jerking movements. The 2 staff members who observed C1 during the incident also denied the observation of C1 displaying jerking movements resembling a seizure. Staff denied informing C1’s responsible party that C1 had a seizure.

Staff stated that while waiting for the paramedics to arrive, the staff had turned C1’s chair around to take C1’s pulse and respiration vitals. This staff denied taking C1’s blood pressure.

3 out of 3 staff who observed C1 during the incident denied C1 collapsing to the floor. It was stated that C1 was sitting in his/her chair the entire time until the paramedics arrived. 1 client was interviewed who observed the incident. The client denied C1 collapsing to the floor and stated that C1 was observed sitting down on the chair when C1 put his/her head down.

Based on staff interview, when the paramedics arrived, staff provided the paramedics with C1’s emergency form and the paramedics took over C1’s care.

Based on record review of C1’s emergency form, it’s written that C1 is diagnosed with brittle bone disease.

Staff stated that when the paramedics arrived, he/she did inform the paramedics that C1 had brittle bone. Staff stated that C1’s responsible party (RP) was put on speaker phone when C1’s RP instructed staff to inform the paramedics not to leave the blood pressure cuff on C1, which the paramedic heard and informed his/her colleagues. C1 was placed on a stretcher and was transported to the emergency room. Page 2 of 3.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250103145337
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: 04/16/2025
NARRATIVE
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The review of records indicated that C1 sustained multiple fractures, however, there is not enough evidence to prove the fractures were sustained at the day program.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicated that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Program Director (PD) Raul Regencia and a copy of the report was provided.

Page 3 of 3.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3