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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202845
Report Date: 09/27/2023
Date Signed: 09/27/2023 12:43:41 PM

Document Has Been Signed on 09/27/2023 12:43 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 INC.FACILITY NUMBER:
435202845
ADMINISTRATOR:MIRELEZ, RAYFACILITY TYPE:
775
ADDRESS:220 SOUTH MAIN STTELEPHONE:
(408) 661-4883
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 135CENSUS: 113DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Ray MirelezTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit today, and met with(ADM) Administrator Melissa Ramos.

During visit, ADM stated the facility has 113 clients total and 39 staff total. LPA toured the facility inside and out. The tour included the following; 2 large activity rooms, backyard patio area, quiet room, 2 kitchens, a computer room, office areas, bathrooms and storage area. LPA observed two activity areas; which included a activity tables and numerous amounts of activities available to clients to use.

LPA observed 2 men's restrooms, 2 women's restrooms and a shower room. LPA also observed 3 additional gender neutral restrooms. LPA observed toiletries and covers on the trash can. LPA measured hot water temperatures in the facility restrooms, between 112 to 116 degrees F.

LPA observed a dual fire alarm system with carbon monoxide detectors in all areas. The facility's Last disaster drill was conducted on September 8, 2023. There were 4 fire extinguishers observed in the facility and were last serviced in July 19th 2023. ADM stated that the facility has 9 transportation vans and are serviced based on mileage or as needed.

LPA reviewed a random selection of clients and staff files. 3 Out 3 clients' records were reviewed and were complete such as Needs and Services Care plans and physicians assessments/TB clearances. 3 Out of 3 Staff files were reviewed with current training, required training, including first aid and CPR on file, physicians assessments/TB clearances, and are fingerprint cleared and associated.

Exit interview was conducted with ADM Ray Mirelez. No deficiencies cited.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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