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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011404238
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:24:42 PM

Document Has Been Signed on 01/12/2024 04:24 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
E BAY DELTA AC/SC, 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: 26DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:David de Alemeida, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 01/12/2024 at 10:30AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Direct Support Professional, Donny Brown and explained the purpose of the visit. Donny phoned Administrator, David de Alemeida to inform. The facility’s fire clearance was approved for capacity 28 Ambulatory. Administrator Certificate #6039202735 Expires 04/25/2024.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 28 total bedrooms which 28 bedrooms are occupied by the clients and 2 bedroom is occupied by staff. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.4 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/27/2022. Emergency Disaster Drill was last posted on 10/20/2015. First aid kit was observed to be complete. Fire drill was last conducted 10/25/2023.

At 11:00AM, 6 of 6 clients records were reviewed. At 12:00PM, 6 of 6 staff records were reviewed and 6 of 6 have current first aid training and associated to the facility.

LIC809-C Continued....
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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 16
Document Has Been Signed on 01/12/2024 04:24 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 01/12/2024 at 02:36 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: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having the bathrooms cleaned, the toilets clean, the floors mopped which poses a potential health and safety risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agrees to clean the bathrooms and will submit photos to CCLD by POc due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having paint cans, dressers, pots, tool box, TV, bicycle, mattresses, wood planks located near Bedroom#8 (facility sketch 02.14.05) which pose a potential health and safety risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agrees to remove paint cans, dressers, pots, TV, mattresses, wood planks and submit building permit and project plan and photos to CCLD by POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 16
Document Has Been Signed on 01/12/2024 04:24 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 01/12/2024 at 02:36 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: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having a health screening for S2, S4 and S5 which poses a potential health and safety risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agrees to complete a health screening for S2, S4 and S5 and submit a copy to CCLD by POC due date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not having a TB test for S5 which poses a potential health and safety, personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will get a negative TB test for S5 and submit a copy to CCLD by POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 16
Document Has Been Signed on 01/12/2024 04:24 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 01/12/2024 at 02:36 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: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in by not having non-persishablefresh perishable foods available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will purchase non-perishable foods (e.g., canned tuna) and perishable foods (e.g., eggs, apples, oranges, bananas etc...) will submit photos of food purchases with receipt to CCLD by POC due date.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having a TB tests on file for C2 and C5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will get a negative TB tests for C2 and C5 and submit a copy to CCLD by POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 16
Document Has Been Signed on 01/12/2024 04:24 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 01/12/2024 at 03:08 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: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80024
80024 Waivers and Exceptions

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above in not having an age exception for C4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agrees to send an age exception request for C4 to CCLD by POC due date.
Type B
Section Cited
CCR
85068.4
85068.4 Acceptance and Retention Limitations


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in not having updated Physician's Report for C4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agrees to get an updated Physician's Report for C4 and submit to CCLD by POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TIA MARIA FAMILY HOME
FACILITY NUMBER: 011404238
VISIT DATE: 01/12/2024
NARRATIVE
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LIC809 Continued...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 12:37pm, LPA observed dressers, paint cans, pots, tool box, TV, bicycle,
mattress located outside on the side and backyards

At 1:00PM, LPA observed 2-3 car batteries, wood, doors located outside in driveway by garbage

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/26/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan (9 pages)
Liability Insurance
Updated Facility Sketch


Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 15 of 16
Document Has Been Signed on 01/12/2024 04:24 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 01/12/2024 at 03:57 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: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation andinterview, the licensee did not comply with the section cited above in not having current tagged fire extinguishers which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agrees to call Fire Department and get expired fire extinguishers updated and tagged.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
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