<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011404238
Report Date: 11/08/2023
Date Signed: 11/08/2023 02:10:51 PM

Document Has Been Signed on 11/08/2023 02:10 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:MARIA A. DE ALMEIDAFACILITY TYPE:
735
ADDRESS:28175 RUUS ROADTELEPHONE:
(510) 887-6221
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 28CENSUS: 28DATE:
11/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:David De AlmeidaTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Fontanilla conducted case management in connection with complaint # 15-AS--20230316100902 to address the facility’s failure to submit incident reports and maintaining client records. LPA spoke with Administrator David De Almeida.

During the course of investigation, there were inconsistencies regarding the maintaining of client records for C1. Administrator Anita De Almeida reported an unidentified Telecare staff removed records from C1’s file. Telecare Clinical Director denied the agency had the records.

Anita stated she reported multiple incidents of C1’s drug use to CCL. LPA L. Fontanilla was unable to locate the records. Anita did not have additional copies of all incident reports to provide to the Investigations Branch (IB).

Deficiency is cited per Title 22 California Code of Regulations(refer to Lic 809D)

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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
Document Has Been Signed on 11/08/2023 02:10 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 11/08/2023 at 01:47 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
80061(a)

1
2
3
4
5
6
7
80061 Reporting Requirements
a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department….
This requirement is not met as evidenced by:
Based on record review conducted, facility failed to report incidents including but not limited to C6 overdosing with drugs which resulted to C6’s death, incidents when staff observed clients using drugs at the facility, etc which poses an immediate threat to health and safety of other clients in care.
1
2
3
4
5
6
7
Plans of Corrections (POCs) will be addressed in a Non Compliance Conference(NCC).
Type B
11/10/2023
Section Cited
CCR
80070(a)

1
2
3
4
5
6
7
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
Based on the investigation conducted by the Department, the facility failed to maintain C2’s file at the facility which poses a potential risk to health and safety of clients under care.
1
2
3
4
5
6
7
POCs will be addressed in a Non-Compliance Conference (NCC).

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2