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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200543
Report Date: 05/10/2023
Date Signed: 05/10/2023 03:37:48 PM


Document Has Been Signed on 05/10/2023 03:37 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Daphna Garcia/Administrator
and Sharon Blackwell/Staff		TIME COMPLETED:
03:35 PM
NARRATIVE
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On this day, May 10, 2023, at 11:00 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Daphna Garcia, administrator, and informed the reason for visit. LPA also met with other staff, Sharon Blackwell.

Facility has an approved LIC808 Mitigation Plan and has submitted the current/updated LIC9282 Infection
Control Plan.

LPA inspected the facility inside and out including but not limited to living room. bedrooms, bathrooms, laundry area, kitchen, dining area, activity/family room, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced January 4, 2023. Facility has 2 in 1 carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in the common bathroom was teste, and measured at 118.7 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted April 19, 2023.

LPA reviewed 2 residents and 3 staff files, and interviewed 2 staff and 2 residents. Medications were checked and compared with records and doctor's orders. Residents' cash resources reconciled with records.

LPA observed the following:
- at 11:40 am. multi vitamins in resident's room
-at 2:00 pm, resident has doctor's order for eye drops but facility does not have it.


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/10/2023
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LPA obtained the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. Proof of Surety Bond coverage

Administrator to submit a copy of LIC610D Emergency Disaster Plan (9 pages) by May 24, 2023.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

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

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/10/2023 03:37 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
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: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for resident having doctor's order for eye drops on file but facility does not have the medication which poses an immediate health and personal rights risks to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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Administrator to call the resident's doctor to check if the medication is still needed by the resident. If it is, obtain the medication; otherwise, obtain a discontinued order. Proof to be submitted by 5/11/23.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 having muntivitamins in resident's room which poses an immediate health risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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Administrator took and locked the items.
In addition, administrator to conduct in-service training, and submit copy with attendees signatures by 5/11/23.
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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3