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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200543
Report Date: 05/07/2025
Date Signed: 05/07/2025 04:20:17 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
04/09/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250409190945
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:
05/07/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Daphna Garcia/Administrator TIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Licensee made alterations to the garage.
INVESTIGATION FINDINGS:
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On this day, May 7, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a subsequent investigation of the above allegation. LPA met with Daphna Garcia, administrator (ADM), and informed the reason for visit.

LPA conducted inspection of the garage and observed that a division wall, 2 heaters, toilet, electrical wiring and lights, and sliding door on 1 side and another door on the other side were installed.

Based on observation, the prepondance of evidence standard has been met, therefore, the allegation is substantiated.


....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
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 4
Control Number 15-AS-20250409190945
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: 05/07/2025
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations and listed on 9099C. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed ADM. LPA called and left message on Kim Fields, licensee, voicemail.

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

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250409190945
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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
Section Cited
CCR
80086(a)
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80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

-This requirement is not met as evidenced by:
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Licensee to read the Regulations and ensure compliance. Self-certication to be submiitted by 5/21/25.
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-Based on observation and interview, the licensee did not comply with the section cited above in not notifying licensing prior to doing the alterations which poses potential safety and/or personal rights risks 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: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4