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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200543
Report Date: 12/18/2024
Date Signed: 12/18/2024 01:56:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20241213155842
FACILITY NAME:WORTHY HOUSE #1FACILITY NUMBER:
019200543
ADMINISTRATOR:DAPHNA GARCIAFACILITY TYPE:
735
ADDRESS:568 MEEK AVENUETELEPHONE:
(510) 583-1160
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 2DATE:
12/18/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Daphna Garcia/AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee spoke to client in an inappropriate manner.

Staff (S1) working in the facility is not fingerprint cleared.
INVESTIGATION FINDINGS:
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On this day, 12/18/24, at 10:10 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10-day complaint visit. LPA met with Daphna Garcia, administrator, and informed the reason for visit. LPA spoke on the phone with Kim Fields, licensee.

LPA obtained copies of LIC500 Personnel Report and conducted interviews.

LPA interviewed staff (S1, S2 and S3) and clients (C1 and C2).

Allegation: Licensee spoke to client in an inappropriate manner.
Two out of 3 staff interviewed and both clients stated the licensee screams/yells at clients. Therefore, the allegation is substantitated.

......continued on 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20241213155842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WORTHY HOUSE #1
FACILITY NUMBER: 019200543
VISIT DATE: 12/18/2024
NARRATIVE
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Allegation: Staff (S1) working in the facility is not fingerprint cleared.
Although S1 denied working at the facility, the 2 staff and 2 clients stated S1 works in the facility on weekends. Based on information obtained, S1 worked 3 days this month of December. Licensee stated S1 works to assists her in cleaning. Review of staff roster showed S1 is not fingerprinted and associated. Therefore, the allegation is substantiated.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 9099Ds. A $300.00 civil penalty is assessed for deficiency section 80019(e)(2). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator and on the phone with licensee.

Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20241213155842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WORTHY HOUSE #1
FACILITY NUMBER: 019200543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2024
Section Cited
CCR
80019(e)(2)
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80019 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee to read the Regulations and effective immediately not to allow S1 work in the facility until fingerprint cleared. Self-certification to be submitted by 12/19/24.

A $300.00 civil penalty is assessed.
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-This requirement is not met as evidenced by:
-Based on interviews and review of roster, the licensee did not comply with the section above in having S1 who is not fingerprint cleared work in the facility which poses an immediate safety risk to persons in care.
Civil penalty is assessed.
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Type B
01/01/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
-This requirement is not met as evidenced by:
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Licensee to read the Regulations and self-certify that screaming and/or yelling are stopped. Proof to be submtted by 1/01/25.
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-Based on interviews, the licensee did not comply with the section above in screaming/yelling at clients which poses a potential 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5