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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202845
Report Date: 04/04/2024
Date Signed: 04/04/2024 10:44:58 AM

Substantiated


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
02/15/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240215132728

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: 98DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Assistant Program Director Jesus GomezTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Staff video recorded a resident without their permission
INVESTIGATION FINDINGS:
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On February 15, 2024, the Department received a complaint alleging staff video recorded a resident without their permission.

On October 12, 2023, Local Law Enforcement (LLE) responded to a report that on October 9, 2023, that facility staff had allegedly pulled Client (C1)’s hair and yelled at him/her.

LLE interviewed S4. S4 stated he/she took a video of the tantrum at the urging of one of the behavioral counselors. S4 stated the counselor had requested a video so they could have a better idea of how C1 acts during a tantrum. S4 showed law enforcement the video and provided law enforcement with a copy.

On February 22, 2024, LPA Monter interviewed S4. S4 stated he/she did record C1. ADP stated the video recording had been deleted. S4 stated they had a conversation with the crisis team regarding video recording requesting more details to know how C1's tantrums were taking place.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20240215132728
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: 04/04/2024
NARRATIVE
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LPA interviewed C1’s Responsible Party (C1RP). C1RP stated he/she did not give the day program permission to film C1.

LPA interviewed client C1. C1 stated he/she did not give the S4 permission to video record him/her.

Based on a review of Mission Bay’s Photograph Release form, dated July 26, 2023, C1’s conservator does not consent for photographs to be taken of C1.

The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Assistant Program Director Jesus Gomez and a signed copy of this report was provided along with appeal rights.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20240215132728
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/05/2024
Section Cited
CCR
82072(a)(1)
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 82072 Personal Rights (a)(1) To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement was not met as evidence by:
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ADM stated he will ensure they have a consent form before recording a resident. ADM stated he will send a letter of understanding regading the regulation. ADM stated he will send the letter by POC date, April 5, 2024.
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Based on interviews conducted and records reviewed, S4 admitted to video recording C1 during a tantrum without obtaining consent from the responsible party. This poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6