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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011404238
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:50:15 PM

Document Has Been Signed on 12/08/2023 03:50 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:
12/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Donny BrownTIME COMPLETED:
04:00 PM
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On this day at around 3:15 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit to obtain records of client 1 (C1). LPA was met by staff Donny Brown. LPA explained to Brown the purpose of the visit. Administrator David de Almeida was informed over the telephone about the visit. He authorized Brown to sign the report.

During the visit, LPA obtained the following records:
  • Hayward Police Department contact information card
  • Death Report
  • Personal Rights
  • Admission Agreement
  • Client/Resident Personal Property Inventory
  • Identification and Emergency Information
  • Physician's Report
  • Functional Capability Assessment
  • Preplacement Appraisal
  • Consent for Emergency Medical treatment



A copy of this report was provided to Brown.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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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