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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011404238
Report Date: 10/06/2021
Date Signed: 10/06/2021 02:57:59 PM

Document Has Been Signed on 10/06/2021 02:57 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:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Anita Dealmeida, AdministratorTIME COMPLETED:
03:15 PM
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On 10/6/2021 at 11:30AM, Licensing Program Analysts (LPA) Catherine Lin arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Anita Dealmeida and explained the purpose of the visit.

Upon entry, LPA's temperature was checked by Anita and asked Covid-19 symptoms questions. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. Hand washing posters were posted at bathrooms and sinks.

During record review, Facility has a copy of Mitigation Plan and Disaster Emergency Plan on file. LPA observed PPEs, food, and paper supplies are sufficient.

No deficiency cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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