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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202845
Report Date: 05/23/2025
Date Signed: 05/23/2025 09:46:03 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
02/19/2025 and conducted by Evaluator Marcela Yanez
COMPLAINT CONTROL NUMBER: 26-AS-20250219135022
FACILITY NAME:MISSION BAY INC.FACILITY NUMBER:
435202845
ADMINISTRATOR:MIRELEZ, RAYFACILITY TYPE:
775
ADDRESS:220 SOUTH MAIN STTELEPHONE:
(408) 661-4883
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:135CENSUS: 108DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jesus Gomez, Assistant Program DirectorTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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9
Staff member physically abused client in care causing injuries.
INVESTIGATION FINDINGS:
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On 05/23/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Assistant Program (APD) Director Jesus Gomez. LPA stated the purpose of the visit.

On 02/19/25 the department received a complaint with the allegation that Staff member physically abused client in care causing injuries.

On 02/20/25 Licensing Program Analysts (LPAs) Marcela Yanez and Kiran Jain conducted an initial complaint investigation. During visit LPAs reviewed records for 3 Clients (C1, C2 and C5) and interviewed Staff 1 (S1) and 1 client (C5).

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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 2
Control Number 26-AS-20250219135022
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: 435202845
VISIT DATE: 05/23/2025
NARRATIVE
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On 05/09/25 LPA Yanez conducted a continuation complaint investigation visit. LPA interviewed 5 Staff (S1 to S5), APD and 4 Clients (C4 to C7).

During investigation LPA interviewed Witness (W1). who stated that C5 has self-injury behavior. 1 out of 5 clients stated that C5 harms thyself.

LPA interviewed 5 Staff (S1-S5). 5 out of 5 staff stated that C5 has self-injury behavior and that he/she tries to hit other clients and needs constant supervision.

LPA reviewed 3 out of 3 Client record and observed that C5 appraisal needs and services has a history of self injurious behavior.

Based on document reviews and interviews the department has completed its investigation and found that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the above allegation did or did not occur, therefore the above allegations are unsubstantiated.

No deficiencies are being cited during today’s visit based on California Code of Regulations Title 22. An exit interview was conducted with Assistant Program Director Jesus Gomez and a copy of the report was provided.

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End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2