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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200543
Report Date: 04/30/2024
Date Signed: 04/30/2024 07:36:35 PM

Document Has Been Signed on 04/30/2024 07:36 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/
DIRECTOR:		DAPHNA GARCIAFACILITY TYPE:
735
ADDRESS:568 MEEK AVENUETELEPHONE:
(510) 583-1160
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 2DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Daphna Garcia/Administrator TIME VISIT/
INSPECTION COMPLETED:
07:40 PM
NARRATIVE
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 At 1:20 p.m., on this day, April 30, 2024, 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.

Administrator submitted a copy of Infection Control Plan which LPA received on May 5, 2023.

LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining area, living room. bedrooms, bathrooms, activity/family room, front, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications is locked in the office.

Fire extinguishers were observed fully charge with tags showed serviced December 18, 2023. Facility has carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in one of common bathrooms was tested, and measured at 108 degrees Fahrenheit. Facility conducts fire and earthquake drills at least every quarter, and records showed last conducted April 12, 2024 and February 21, 2024 respectively.

LPA reviewed 3 staff and 2 residents records, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I were checked and compared with last recorded balance.


...continued on 809
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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: 04/30/2024
NARRATIVE
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LPA observed the following:
-at 1:30 p.m, expired cheese spread (expiration: 4/21/24)
-at 1:50 p.m., pieces of tiles and broken refrigerator in the backyard.
-at 3:10 to 3:20 p.m., no LIC9172 Functional Capability Assessment for residents (R1 and R2).
-at 4:00 p.m., R2 has 2 medications listed on After Visit Summary dated 4/29/24, but facility does have the medications.
-at 4:20 p.m. to 4:35 p.m., R1's quantity of 2 medications listed on LIC622 Centrally Stored Medication and Destruction Records does not match the actual quantity received by the facility. R2's all medications does have the dates medications were started on LIC622.

Administrator to submit an updated/current copies of the following documents by May 14, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction dues 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 and staff.

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: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/30/2024 07:36 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/30/2024 at 06:22 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in facility not having the 2 medications for R2 which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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2
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Administrator to check with the doctor if the 2 medications are needed and obtain them, otherwise, obtain a discontinued order. Proof to be submitted by 5/01/24,
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in expired cheese spread which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Administrator to in-service the staff and submit proof by 5/01/24.
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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/30/2024 07:36 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/30/2024 at 06:22 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in pieces of tiles and broken refrigerator in the backyard which pose a potential safety and/or personal rights risks to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Administrator to have the yard cleaned and submit picture by 5/14/24.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R1 and R2 not having LIC9172 Functional Capability Assessment which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Administrator to complete LIC9172 and submit self-certification by 5/14/24.
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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/30/2024 07:36 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/30/2024 at 06:35 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in the following which pose potential personal rights risk to persons in care: R1's quantity of 2 medications listed on LIC622 Centrally Stored Medication and Destruction Records does not match the actual quantity received by the facility. R2's all medications does have the dates medications were started on LIC622.
POC Due Date: 05/14/2024
Plan of Correction
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Corrected.
Administrator corrected the LIC622 while LPA was at the facility.
Section Cited
Deficient Practice Statement
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2
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4
POC Due Date:
Plan of Correction
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4
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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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