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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011404238
Report Date: 03/20/2023
Date Signed: 03/20/2023 01:35:34 PM

Document Has Been Signed on 03/20/2023 01:35 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: 27DATE:
03/20/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David de Almeida, AdministratorTIME COMPLETED:
12:00 PM
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On 03/20/23 at 11AM, while at the facility for another reason, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 1 complaint. LPA explained the purpose of the visit with administrator.

During the health and safety check, LPA observed a total of 3 staff members and 27 clients at the facility. LPA toured facility with staff (DSP 2), including but not limited to bedrooms, kitchen, bathroom, and common areas. Clients in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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