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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200543
Report Date: 05/07/2025
Date Signed: 05/07/2025 04:50:23 PM

Document Has Been Signed on 05/07/2025 04:50 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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
05/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Daphna Garcia/Administrator TIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On this day, 5/07/25, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Daphna Garcia, administrator (ADM), and informed the reason for visit. Kim Fields, licensee, arrived at around 12:15 pm and have to leave after several minutes.

LPA toured the facility inside out with ADM. 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 24, 2024. 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 111.8 degrees Fahrenheit. Facility conducts fire and earthquake drills at least every quarter, and records showed last conducted April 23, 2025 and March 24, 2025 respectively.

LPA reviewed 5 staff and 2 residents records. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&Is were checked and compared with last recorded balance.

LPA observed the following:
-at 12:09 p.m., pizza cutter and 2 kitchen shears in kitchen drawer without lock.

...continued on 809C
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201
DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/07/2025
NARRATIVE
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-at 12:30 p.m., alterations in the garage - division wall, 2 heaters, toilet, electrical wiring and lights, and sliding door on 1 side and another door on the other side were installed. LPA verified, and per ADM, permit was not obtained prior to alterations.
-at 1:30 p.m., 2 of resident's (R1) medications filled on 4/29/25 were not recorded on LIC622 Centrally Stored Medication and Destruction Records.

LPA observed that the Accessory Dwelling Unit (ADU) erected behind the facility which was discussed with ADM has been completed. An LIC809 Case Management Report pertaining to the ADU was provided on 4/30/24 to ADM. Copy of the building permit for ADU was obtained by LPA on this same day, 5/07/25. ADM to submit by May 21, 2025 the following:
  • updated facility sketch showing the dimensions of each room; use of each room; number of resident(s) in each room
  • exit doors and windows
  • garage including dimensions, division wall, toilet, doors and windows
  • sketch of the property lay out showing the buildings (facility and ADU), garage, driveway, storage, utility shut off locations and perimeter fence, ADU intended occupants (staff)

Administrator to submit an updated/current copies of the following documents by May 21, 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 ADM. LPA left message on licensee voicemail.

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: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/07/2025 04:50 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: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not notifying licensing prior to doing the alterations of the garage which poses potential safety and/or personal rights risks to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Licensee to read the Regulations and ensure compliance. Self-certication to be submiitted by 5/21/25.
Type B
Section Cited
CCR
80086(c)
80086 Alterations to Existing Building or New Facilities
(c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not obtaining a permit prior to alterations of the garage which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Licensee to obtain permit and submit proof by 5/21/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/07/2025 04:50 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: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on record review, the licensee did not comply with the section cited above in not recording on LIC622 the 2 of residents (R1) medications which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Corrected.
Administrator recorded the medications while LPA was at the facility.
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.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/07/2025 04:50 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: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
80087(a)
80087 Buildings 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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Based on observation, the licensee did not comply with the section cited above in pizza cutter and 2 kitchen shears in kitchen drawer without lock which pose an immediate safety and/or personal rights risks to persons in care.
POC Due Date: 05/08/2025
Plan of Correction
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Administrator locked the items.
In addition, administrator to in-service the staff and submit proof by 5/08/25.
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.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

LIC809 (FAS) - (06/04)
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