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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011404238
Report Date: 12/29/2022
Date Signed: 12/29/2022 11:26:07 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2022 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20221025153132
FACILITY NAME:TIA MARIA FAMILY HOMEFACILITY NUMBER:
011404238
ADMINISTRATOR:MARIA A. DE ALMEIDAFACILITY TYPE:
735
ADDRESS:28175 RUUS ROADTELEPHONE:
(510) 887-6221
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:28CENSUS: 25DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David De Almeida, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Client was left in soiled diaper
Client mattress has urine stain
Client mattress is not equipped with proper linen
INVESTIGATION FINDINGS:
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On 12/29/2022 at 11:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and Lisha Holmes arrived unannounced to delivered finding for the above allegations. LPAs met with Administrator David De Almeida and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, reviewed records, collected documents, and interviewed 3 staff and 8 residents. Based on information obtained, it was alleged clients was left in soiled diaper, clients mattress had urine stain, and client mattress is not equipped with proper linen. However, 8 clients state that the facility staffs always encouraged clients to always takes a shower/ change clothing whenever anyone had an accident”. Clients states that staffs here always encourage that client to take a shower and change of clothing.

Report continue on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 2
Control Number 15-AS-20221025153132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TIA MARIA FAMILY HOME
FACILITY NUMBER: 011404238
VISIT DATE: 12/29/2022
NARRATIVE
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LPA interview S1 and had a toured in the 8 client’s rooms which are shared rooms equal a total of 18 beds. LPA observed that there is extra mattress that located in storage room in case any client’s needs to a mattress change. LPA observed 8 clients’ room all are equipped with proper linen.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with David Administrator. A copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2