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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202845
Report Date: 09/21/2022
Date Signed: 09/21/2022 10:41:29 AM

Document Has Been Signed on 09/21/2022 10:41 AM - 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 INC.FACILITY NUMBER:
435202845
ADMINISTRATOR:MIRELEZ, RAYFACILITY TYPE:
775
ADDRESS:220 SOUTH MAIN STTELEPHONE:
(408) 661-4883
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 135CENSUS: 0DATE:
09/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Maria CockerTIME COMPLETED:
10:45 AM
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Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai arrived announced to conduct the facility's pre-licensing visit. LPAs met with Licensees Maria Coker and Brandon Coker. There are no clients present on site.

During visit, LPAs toured the facility to include the activity rooms, kitchens, storages, bathrooms, and exterior. All fire exit routes were free and clear of obstruction. Toxins observed secured. Facility has an approved fire clearance for 135 non-ambulatory clients.

Facility has a central entry point for symptom screening and temperature check for all clients, staff, and visitors. Bathrooms supplied with hand washing sign, hygiene products, and paper supplies. LPAs observed the carbon monoxide detectors to be in working condition. Hot water temperature maintained between 105.9 - 122.7 degrees Fahrenheit. Facility temperature maintained between 70 - 73 degrees Fahrenheit. First aid kit supplied with tweezers, bandages, gauze, scissors, and thermometer. Battery operated flashlights observed on-site. Medications will be stored in a locked cabinet. Kitchen observed to have areas to lock sharp supplies. LPAs observed the facility to have Personal Protective Equipment (PPE) supplies. The following posters observed to include the emergency telephone numbers, personal rights, rights of individuals with developmental disabilities, activity schedule, required mask, and facility sketch.

No issues noted during this pre-licensing inspection.

LPAs observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Maria Coker and Brandon Coker and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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