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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 12:48:34 PM

Document Has Been Signed on 09/27/2023 12:48 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Ray MirelezTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Monter conducted an unannounced case management visit regarding an incident report. LPA met with (ADM) administrator Ray Mirelez & explained the purpose of the visit.

On 09/19/2023, the department received an in incident report alleging R1 was kicked by a day program staff. The incident report stated the following; on 09/07/2023, Crisis Response Project contact R1's care home to report that R1 had told them that a staff member at the day program he/she attends, kicked him/her. Note: home staff checked R1 for injury and found none.

On 09/18/2023, the department received an incident report from Mission Bay regarding the allegation that staff were kicking R1. The incident report states the following; at 9/15/2023, the ADM was informed that R1 was alleging that on 09/07/2023, R1 was kicked by staff. ADM conducted an investigation and these were the findings; on 9/7/2023, R1 was reminded by staff to pick up his/her pants. R1 began to yell obscenities and attempted to run away. R1 proceeded to kick his/her staff 3x on the right leg. R1 also threw his/her headphones. Staff were able to calm down R1. ADM asked R1 if he/she wanted to stay in the kitchen area or go to the reflection room. R1 stated he/she wanted to stay in the kitchen area. R1 would go through periods of agitation and yelling at others, then calming down. Staff offered R1 choices to assist him/her to clam down, but R1 refused and remained in the kitchen. These behaviors were documented by staff. LPA requested a copy of the notes.

LPA interviewed 3 staff members who were present and in the immediate area during the incident on 09/07/2023. 3 out of 3 staff members interviewed denied the allegation that staff members kicked R1. R1 was not interviewed. R1 did not attend day program this day.

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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