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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202261
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:02:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 26-AS-20230724094344
FACILITY NAME:MISSION BAY LAS COLINASFACILITY NUMBER:
435202261
ADMINISTRATOR:MARIA COKERFACILITY TYPE:
775
ADDRESS:50 LAS COLINAS LANETELEPHONE:
(408) 661-4883
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY:177CENSUS: 173DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Dennis Miclat TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff is unable to manage resident’s behavior resulted in property destruction and self-injurious behavior

Staff physically hit a resident which resulted in bruising
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Dennis Miclat and explained the reason for the visit. Census: 173

Staff is unable to manage resident’s behavior resulted in property destruction and self-injurious behavior - LPA Lund reviewed facility records, interviewed staff, reporting party, witnesses, and clients in care. Based on facility records reviewed, interviews with staff, reporting party, witnesses and clients in care. The day program turned in a Special Incident Report dated July 7, 2023, which states that client (C1) on July 6, 2023, C1 started screaming, crying, throwing himself against plexiglas glass and couch. C1 also was hitting self in the face and neck. Staff and lead staff redirected C1 to the quite room. C1’s father came to pick up C1 and was noted that C1 was still agitated and didn't calmed down.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
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 2
Control Number 26-AS-20230724094344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: MISSION BAY LAS COLINAS
FACILITY NUMBER: 435202261
VISIT DATE: 12/12/2024
NARRATIVE
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C1 LIC(625) Appraisal Needs and Service Plan states that C1 is monitored for physical aggression (Hit, grab, throw objects), disruptive behavior (Property destruction, loud vocalization, and grabbing food). Body checks are checks are done during pick up and drop off. LPA Lund reviewed C1’s Mission Bay Works Adult Day Program Body Check Forms dated July 3, 2023, through July 31, 2023, states that C1 did not have any marks when C1 arrived on July 6, 2023. The facility was not able to do a body check when C1 left the facility on July 6, 2023, due to C1’s incident and dad coming to pick up C1.

Based on facility records reviewed, interviews with staff, reporting party, witnesses and clients in care on the information provided, it was unclear if staff is unable to manage resident’s behavior resulted in property destruction and self-injurious behavior, therefore the allegation was deemed UNSUBSTANTIATED.



Staff physically hit a resident which resulted in bruising- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on facility records review, interviews with staff, and clients in care. On July 6, 2023, Client (C1) started screaming, crying, throwing himself against plexiglas glass and couch. C1 also was hitting self in the face and neck. Staff and lead staff redirected C1 to the quite room. C1’s father came to pick up C1 and was noted that C1 was still agitated and not have calmed down when leaving. The day program turned in a Special Incident Report dated July 7, 2023, for the incident on July 6, 2023. LPA reviewed Abuse, Neglect, and Exploitation in the Elder Care Setting for management and Abuse and Neglect for staff. Staff interviewed stated “That they have never witnessed any staff hit any clients in care”. Clients interviewed stated “They have never been hit or seen any clients in care been hit”.

Based on facility records review, interviews with staff, and clients in care on the information provided, it was unclear if staff physically hit a resident which resulted in bruising, therefore the allegation was deemed UNSUBSTANTIATED.



As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2