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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 07:15:29 PM

Document Has Been Signed on 04/30/2024 07:15 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: DATE:
04/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Daphna Garcia/Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On May 10, 2023, during last year's annual inspection, Daphna Garcia, administrator, informed Licensing Program Analyst (LPA) Delmundo of the licensee's plan to have an Accessory Dwelling Unit (ADU) erected behind the facility. LPA discussed the following: obtaining permit prior to construction; ensuring the health and safety of residents. At that time, the licensee has not decided if the ADU will be use by the staff. LPA told the the administrator to inform LPA when final decision in made to have ADU added.

On April 25, 2024, the administrator informed LPA that she has not received a definite response from licensee regarding the ADU. The ADU will have a different address, 566 Meek Avenue. A building permit has been obtained and the construction company already started on the ADU.

On this day, April 30, 2024, while doing annual inspection, LPA observed the construction of ADU has started. LPA obtained copy of building permit from the administrator. LPA also spoke over the phone with Kim Fields, licensee, and discussed the following in the presence of the administrator.
1. Adding perimeter fence to separate the facility from the ADU and obtaining a permit if required by the city.
2. Submission of updated facility sketch showing the new property line.
3. Submission of application for license to Sacramento for the 566 address if the plan is to operate another assisted living facility.

Exit interview conducted and copy of this report provided to the administrator.
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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