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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200543
Report Date: 05/20/2022
Date Signed: 05/20/2022 06:31:06 PM

Document Has Been Signed on 05/20/2022 06:31 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:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Daphna Garcia/Administrator TIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Daphna Garcia, administrator, and informed the purpose of visit. LPA also met with other staff, Sharon Blackwell.

Facility has an approved LIC808 Mitigation Plan on file. All 3 staff were fit tested for N95 respirator; 2 on June 25, 2021 and the other staff on July 21, 2021. Daphna stated they will re-fit tested by next month.

LPA inspected the living room, dining area, kitchen, bathrooms, family/recreation room, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch probe thermometer. Surgical masks and disposable gloves are readily available at the screening station. Visitor's temperature and symptom checking are done at entry for visitors. Residents and staff are screened for COVID-19 symptoms, and temperature is checked daily; however, facility does not keep record for the staff. Facility check for proof of vaccination of visitors and antigen test kits are readily available. COVID-19 signages were observed posted all throughout the facility. Supplies of PPEs were checked.

Hot water temperature in one of common bathrooms was tested and measured at 110 degrees Fahrenheit. Fire extinguishers checked and observed fully charge with tags showed serviced August 3, 2021. The two-in-one smoke and carbon monoxide detector was tested and observed operational.

......continued next page
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 05/20/2022
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At around 4:35 pm, LPA observed common towel in the bathroom.

Administrator to submit updated copies of the following documents by June 3, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. Proof of Surety bond coverage

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Daphna Garcia.

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: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2022 06:31 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/20/2022 at 06:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WORTHY HOUSE #1
FACILITY NUMBER: 019200543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85088(c)(4)(B)


85088 Fixtures, Furniture, Equipment and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.
(4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and washcloths.
(B) The use of common towels and washcloths shall be prohibited.


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. Common towel was observed in the bathroom which poses potential health risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Administrator stated she'ls have a paper towel holder installed and ensure provision of paper towel. Picture to be submitted by June 3. 2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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