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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202261
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:09:44 PM

Document Has Been Signed on 05/01/2025 02:09 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:MISSION BAY LAS COLINASFACILITY NUMBER:
435202261
ADMINISTRATOR/
DIRECTOR:		MARIA COKERFACILITY TYPE:
775
ADDRESS:50 LAS COLINAS LANETELEPHONE:
(408) 661-4883
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 177CENSUS: 168DATE:
05/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Dennis MiclatTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Santino Fortes conducted an unannounced annual inspection, and met with Administrator (ADM) Dennis Miclat. ADM stated facility has 80 staff and 168 clients.

LPA toured the facility inside and out. There were 3 Central activity areas and 8 smaller breakout rooms, 2 staff rooms, outdoor garden area, 2 Kitchens. LPA observed 3 large activity rooms each with various sensory activities, and 8 smaller break out rooms. Each room had sufficient lighting, tables and chairs. Room temperature was 67.5* F. Hot water temperature was: Bathroom, 113.5*F, Bathroom 109* F and kitchen 114* F. LPA observed the first aid kit to be complete. Smoke and carbon monoxide detectors functioned properly when tested. 5 Fire extinguishers were serviced on 5/7/2024. Staff conducted a fire drill on 3/4/25. Restrooms observed to have basic toileting fixtures (no Showers). Residents all brought their own lunches . Refrigerator temperature observed at 42 * F and Freezer temperature 32* F. LPA observed PRN medication storage, and cleaning product storage locked and inaccessible to clients in care.

The areas around the building was inspected. Exits and walkways were unobstructed. Facility has 0 storage sheds. Facility has 18 vans for community outings.

LPA observed Facility License and Resident Personal rights were posted. LPA reviewed facility records for 5 staff, and 5 clients and observed to be complete.

No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with ADM. This report was reviewed and a copy was provided to ADM for signature.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Santino Fortes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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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