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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011404238
Report Date: 09/17/2025
Date Signed: 09/17/2025 03:01:23 PM

Document Has Been Signed on 09/17/2025 03:01 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TIA MARIA FAMILY HOMEFACILITY NUMBER:
011404238
ADMINISTRATOR/
DIRECTOR:		MARIA A. DE ALMEIDAFACILITY TYPE:
735
ADDRESS:28175 RUUS ROADTELEPHONE:
(510) 887-6221
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 28CENSUS: 28DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Anita de Alemeida, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 09/17/2025 at 9:30 AM, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Support Professional, Anita de Alemeida and explained the purpose of the visit. Anita phoned Administrator (ADM), David de Alemeida to inform the purpose of the visit. The facility’s fire clearance was approved for capacity 28 Ambulatory. Administrator Certificate #7011570735 Expires 04/25/2026.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 16 bedrooms total of which 14 bedrooms are occupied by the residents, and 2 bedrooms are occupied by staff. There are no bodies of water. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 139.1-degree Fahrenheit.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/18/2025. Emergency Disaster Drill was last posted on 9/17/2025. First aid kit was observed to be complete. Fire drill was last conducted on 10/25/2024. Liability Insurance coverage date: 7/24/2025 to 7/24/2026

At 12:00PM, 10 of 10 residents’ records were reviewed. At 12:50PM, 6 of 6 staff records were reviewed and 6 of 6 have current first aid training and are associated to the facility.

LIC809 Continued...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/17/2025 03:01 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/17/2025 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TIA MARIA FAMILY HOME
FACILITY NUMBER: 011404238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water measure at 139.1 degree F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator will turn hot water down between 105-120 degree F. and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/17/2025 03:01 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/17/2025 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TIA MARIA FAMILY HOME
FACILITY NUMBER: 011404238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ny having their kitchen not clean including but not limited to refrigerator, floor, cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Administrator (ADM) will clean the whole facility kitchen including but not limited to flooring, cabinet, refrigerator, ect. ADM submit photo to CCLD by POC date.
Type B
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having staff training on files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Administrator (ADM) provided proof of staffs training and submit via to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/17/2025 03:01 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/17/2025 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TIA MARIA FAMILY HOME
FACILITY NUMBER: 011404238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a clean storage space to stored food which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Administrator (ADM) will provided in-services training to staff upon properly storing food and keeping the food storages clean provided proof of in-services and photo of food storage and submit via to CCLD by POC date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having resdients admission agreement on files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Administrator (ADM) completes residents admission agreement and place in files for LPA to receive by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2025 03:01 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/17/2025 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TIA MARIA FAMILY HOME
FACILITY NUMBER: 011404238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having residents needs and service plan on files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Administrator (ADM) completes residents needs and service plan in files for LPA to receive by POC date.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having resident TB test on records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Administrator (ADM) completes residenrs TB result in files for LPA to receive by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2025
NARRATIVE
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LIC809 Continued...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At around 10am, LPAs observed multiple window/ door screens are in disrepair.

At around 10:10am, LPAs observed the light switch in the hallway broken.

At around 10:33am, LPAs observed shared bathrooms are not clean, and missing tank lid for the toilet. There is a hole on top of the bathroom ceiling.

At around 10:35am, LAPs observed hot water measured at 139.1-degree Fahrenheit

At around 10:40am, LPAs observed kitchen was not clean including but not limited to refrigerator, floor, cabinet

At around 10:45am, LPA observed furniture’s are stack in the corner of the activity room and doors panel is in the back hallway, and furniture is leaning on the side of the back house.

At around 10:50am, LPAs observed the side fences leaning towards the neighboring side.

At around 10:51am, during files reviewed resident’s files is incomplete.

At around 12:50 pm, during files reviewing staff’s files is incomplete.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2025
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/30/2025:

LIC 500 Personnel Report

LIC 308 Designation of Administrative Responsibility

LIC 309 Administrative Organization

LIC 400 Affidavit Regarding Client/Resident Cash Resources

LIC 402 Surety Bond

LIC 610D Emergency Disaster Plan (9 pages)

Liability Insurance

Updated Facility Sketch

Exit interview conducted. Appeal Rights and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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