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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200543
Report Date: 06/24/2025
Date Signed: 06/24/2025 06:16:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
06/23/2025 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250623155533
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:
06/24/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Caregiver Thelma BlackTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff did not prevent client in care from getting hit by a non-client youth
INVESTIGATION FINDINGS:
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On 6/24/2025, at 3:30 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced at the facility to investigate the allegation above. Upon entry into the facility, the LPA identified himself and stated the purpose of the visit to Caregiver Thelma Black.

The complaint alleges that staff did not prevent client in care from getting hit by a non-client youth.
The LPA interviewed Witness W1, reviewed the Special Incident Report and Daily Charting Notes on 6/23/2025, and interviewed Staff S1 and S2. The data collected shows that the staff put the client at risk by bringing a non-client youth into the facility and providing inadequate supervision, confirming the allegation.

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED.

Deficiency is cited under the California Code of Regulations listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
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 2
Control Number 15-AS-20250623155533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WORTHY HOUSE #1
FACILITY NUMBER: 019200543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2025
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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On or before the due date, the Administrator shall inform LPA Sampair that they have reviewed with all staff members the rights of clients and the importance of staff doing their job as described to care for and to keep clients safe.
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On 6/23/2025, Staff S1 brought Person P1 into the facility while on duty. S1 did not provide the care and supervision necessary to protect S1 who was hit by P1 with an open hand on their back.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2