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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202845
Report Date: 09/25/2024
Date Signed: 09/25/2024 11:47:25 AM

Document Has Been Signed on 09/25/2024 11:47 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/
DIRECTOR:		MIRELEZ, RAYFACILITY TYPE:
775
ADDRESS:220 SOUTH MAIN STTELEPHONE:
(408) 661-4883
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 135CENSUS: 120DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jesus Gomez - Asst Program DirectorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual inspection visit t and met with Assistant Program Director (APD) Jesus Gomez and stated the purpose of the visit.

The facility is an adult day program licensed to serve the community adults 18 years and over.

At 9:15 a.m. LPA with APD , toured the facility. LPA observed clients leaving to go on their respective field trips. LPA observed classrooms for art and computer workshop. There are lockers for the participants and a refrigerator for the participants to store their belongings and lunches. There 7 restrooms, 2 of 7 has 4 stalls, 2 of 7 has 2 stalls, 1 of 7 is a shower and changing room and 2 of 7 are single use.

The facility has 8 vans use to transport clients to various field trips scheduled for the day. The vehicles are maintained and monitored daily by Fleetio software. APD demonstrated to LPA that Fleetio sends notification to APD and the mechanic if the vehicle requires maintenance or repair.

The facility meets the staffing ratio of 1 staff is to 3 clients. The facility has 2 large activity rooms, backyard patio area, quiet room, 2 kitchens, a computer room, office areas, and storage area. The hot water temperature measured between 105 to 115 degrees Fahrenheit.

The facility is equipped with a fire sprinklers and dual fire alarm system with carbon monoxide detectors strategically placed in the facility. The facility conducts fire and earthquake disaster drill training every 2 months the last training was done on 8/22/2024 for earthquake drill and 9/11/2024 for fire drill. There were 4 fire extinguishers observed in the facility and were last serviced in 12/15/2023.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/25/2024
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The facility has a locked medication room used to store first aid kits and clients medication and is not accessible to clients or unauthorized staff.

LPA reviewed 6 staff record including but not limited to health screening, criminal/fingerprint clearance, required training for the current year and valid 1st aid/CPR certification. Staff record are complete and up to date. LPA reviewed 5 client record including but not limited to admission agreement, consent form, personal rights, physician's report and appraisal needs and services plan. Client's record are complete and up to date.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Asst Program Manager Jesus Gomez and a copy of the report was provided.

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End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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