435202845-10-10-2025-26-AS-CKAI-DPP248-20251224160328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202845
Report Date: 10/10/2025
Date Signed: 10/10/2025 02:46:56 PM

Unsubstantiated

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
07/09/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240709084741

FACILITY NAME:	MISSION BAY INC.		FACILITY NUMBER:	435202845
ADMINISTRATOR:	MIRELEZ, RAY		FACILITY TYPE:	775
ADDRESS:	220 SOUTH MAIN ST		TELEPHONE:	(408) 661-4883
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	135	CENSUS: 124	DATE:	10/10/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Rey Mirelez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not dispense medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Rey Mirelez. On 07/09/2024, the department received a complaint with the above allegation. On 07/11/2024, LPA Marrufo conducted an initial complaint investigation visit. LPA Marrufo conducted an additional complaint visit on 09/26/2025.

During visit on 07/11/2024, LPA Marrufo conducted a medication review of R1’s medication, M1. R1’s Centrally Stored Medication and Destruction Record (CSMDR) states that the bottle of M1 that the facility received on 06/25/2024 had 136 capsules in it. The prescription for M1 requires that R1 be administered 2 capsules per day.

See LIC9099-C pages for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20240709084741

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: 10/10/2025

NARRATIVE

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R1’s Medication Administration Record (MAR) indicates R1 is prescribed 2 capsules per day at 3:00 PM. R1’s MAR records R1 was given 2 capsules of M1 on 06/25/2024, 06/26/2024, 6/27/2024, and 06/28/2024.

R1’s MAR records R1 was given 2 capsules of M1 on 07/01/2024, 07/02/2024, 07/03/2024, 07/05/2024, 07/08/2024, 07/09/2024, and 07/10/2024. From 06/25/2024 to 07/10/2024, there were 11 days in which staff assisted R1 with the administration of 2 capsules of M1, which totals 22 capsules.

During visit on 07/11/2024, staff S1 counted R1’s M1 capsules in front of LPA Marrufo. The number of capsules in the bottle totaled 116. After subtracting 22 capsules from the 136 capsules in the bottle, there should have been 114 capsules remaining. However, there were 116 capsules remaining in the bottle. LPA Marrufo observed that the bottle did not have a start date written on it.

On 02/18/2025, LPA Marrufo conducted an interview with witness W1. W1 stated during interview that W1 brings R1’s M1 medication to the facility once every three months. R1 stated that on one occasion when he/she came to the facility to provide a new bottle of M1 to S2, the previous bottle of M1 had 61 capsules remaining, but there should have only been 2-4 capsules left.

During interview on 09/26/2025, S2 stated that R1's family member would come to the facility every three to six months and provide new bottles of M1. S2 stated that on one occasion, R1's family member came to the facility and retrieved two sealed bottles of M1. S2 stated to have counted the capsules of an open bottle of M1, but the number of capsules in the bottle was not too high. S2 stated that R1's family member provided a bottle of M1 on 06/25/2024. S2 stated he/she mistakenly recorded the start date of that bottle on 06/25/2024, but he/she started pouring capsules from that bottle on 06/26/2024. S2 stated that his/her mistaken start date is why there were 116 capsules in the bottle instead of 114 on 07/11/2024.

During interview on 10/10/2025, ADM stated that the facility policy regarding when a parent of a client picks up unused medications is that the staff responsible for the medications will review the medication count with the parent and sign out the medications.

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SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240709084741

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: 10/10/2025

NARRATIVE

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During visit on 07/22/2025, LPA Marrufo obtained a copy of R1’s CSMDR from March 2024. The CSMDR had a handwritten note that stated that on 03/25/2024, R1’s parent retrieved 260 capsules of M1 and left the facility with a balance of 168 capsules of M1.

During visit on 10/10/2025, LPA Marrufo reviewed R1’s medication record and did not find a sign-out sheet for the capsules of M1 that were stated to have been retrieved by R1’s parent on the March CSMDR.

Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Rey Mirelez and a copy of this report was provided.

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END REPORT

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025

LIC9099 (FAS) - (06/04)

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