011404238-6-14-2024-15-AS-YFLS-D6CNVJ-20240618104755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011404238
Report Date: 11/08/2023
Date Signed: 06/14/2024 02:18:25 PM

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
03/16/2023 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230316100902

FACILITY NAME:	TIA MARIA FAMILY HOME		FACILITY NUMBER:	011404238
ADMINISTRATOR:	MARIA A. DE ALMEIDA		FACILITY TYPE:	735
ADDRESS:	28175 RUUS ROAD		TELEPHONE:	(510) 887-6221
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	28	CENSUS: 28	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	01:27 PM
MET WITH:	David De Almeida		TIME COMPLETED:	01:28 PM

ALLEGATION(S):

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Staff member hits resident
Staff member handles resident in a rough manner
Staff member threatened resident
Resident doesn't feel safe at the facility
Staff member mismanages residents' medication.
Staff did not safe guard resident's personal belongings

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding for the above allegations and met with David De Almeida.

During the course of investigation, the Department interviewed C1, C2, C3, C4 and C5. C3, C4 and C5 denied observing staff physically hurting clients. C3, C4 and C5 state feeling safe and comfortable living at the facility. They also state not having issues with staff at the facility.
However, C1 and C2 both state feeling unsafe and threatened.

C2 alleged Staff 3 punched C2 in the mouth. On 8/7/2023, LPA Fontanilla spoke with S3. S3 denied punching or hurting any client. S3 said the only time S3 had to lay hand on a client was to protect a client when C1 was banging C1’s head on the walls and door. S3 denied the allegation.
Due to conflicting information obtained during interviews, the above allegations are unsubstantiated.
continuation on Lic 9099C ***This is an amended report***

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230316100902

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: 11/08/2023

NARRATIVE

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During interviews conducted by the Department on 4/13/2023, Client 1 (C1) reported staff gave C1 wrong medication approximately 6-8x but failed to provide additional information.

On 7/14/2023, LPA L. Fontanilla spoke with Administrator Anita De Almeida who states C1 was evicted from the facility on May 31, 2023. The Administrator added that the last time she heard about C1 was when C1 got arrested after getting evicted from the facility.

On 7/18/2023, LPA L. Fontanilla received a copy of C1’s Centrally Stored Medication Record (CSMR) for May 2023. David states the facility does not keep a Medication Administration Record (MAR).

On 7/27/2023, LPA reviewed C1’s CSMR and MAR from February – June 2023. For the CSMRs, the start date and expiration dates did not have entries. For the MARs, no signatures or entries were made by facility.

David states C1 was always out of the facility and missed medications. And if C1 was at the facility, C1 was drunk. He added that the facility does not fill out the MARs since they are not required.

During the course of investigation, C1 informed IB investigator that one night in March 2023, C1 observed someone had stolen C1’s recycling items, new clothes and other personal items.

On July 14, 2023, LPA L. Fontanilla interviewed Administrator Anita De Almeida. Anita informed LPA that C1 was evicted from the facility on May 31, 2023. And that C1 still has unclaimed belongings that the facility is keeping for C1. Anita added the belongings appear to be “junk” but they are keeping them for C1, in case C1 comes back for them.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A copy of this report was provided to the Administrator.

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

LIC9099 (FAS) - (06/04)

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