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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011404238
Report Date: 04/19/2024
Date Signed: 04/19/2024 02:15:51 PM


Document Has Been Signed on 04/19/2024 02:15 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:
04/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:David de Almeida, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 04/19/2024 at 10:30 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct Case Management visit. LPA met with Administrator, David de Almeida, and explained the purpose of the visit. LPA conducted an Annual Inspection on 01/12/2024 and cited facility. The original Plan of Correction (POC) was scheduled for 01/26/2024. The administrator requested an extension in which LPA L. Alexander granted the request and confirmed that the new POC due date is 02/09/2024. Due to LPA L. Alexander was not able to return to the facility for a POC visit, LPA returned today to recite for uncleared deficiencies. LPA will cite for renovations that are being done in rear building. Administrator was suppose to submit a proposal with timeline for renovations and that was not submitted as discussed during annual inspection visit on 01/12/2024.

LPA L. Alexander conducted an Annual Inspection on 01/12/2024 and cited facility for the following:

  1. 80069(c)(1) Client Medical Assessments - Not Cleared
  2. 80024 Waivers and Exceptions - Not Cleared
  3. 85068.4(g) Acceptance and Retention Limitations - Not Cleared
  4. 80087(c) Building and Grounds - Cleared


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.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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 3


Document Has Been Signed on 04/19/2024 02:15 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
80069(c)(1)

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(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:
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Administrator will get a negative TB tests for R1 and R2 and submit a copy to CCLD by POC due date.
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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 R1 and R2 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/17/2024
Section Cited
CCR85068.4(g)

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85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age... or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
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Administrator agrees to submit an age exception requests for R1-R6 and submit supporting documents for each resident to CCLD by POC Due Date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above in not having an age exceptions for R1-R6 which poses a potential health, safety or personal rights risk to persons in care.
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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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/19/2024 02:15 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
80086(a)(c)

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80086 Alterations to Existing Building or New Facilities(a) Prior to construction... all licensees shall notify licensing...proposed change.(c) Prior to construction or alterations, state or local law requires...a building permit.

This requirement is not met as evidenced by:
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Administrator agrees to submit a proposed plan with a timeline, updated facility sketch and copy of building permit to CCLD by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above in not notifying CCLD with building alterations/renovations in rear building which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/17/2024
Section Cited
CCR80024

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80024 Waivers and Exceptions

This requirement is not met as evidenced by:
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Administrator agrees to self-certifiy that they read and understand the regulation moving forward and submit to CCLD by POC Due Date
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Based on record review and interview, the licensee did not comply with the section cited above in not submitting an age exception requests for residents over age 60+ which poses a potential health, safety or personal rights risk to persons in care.
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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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3