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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200543
Report Date: 12/18/2024
Date Signed: 12/18/2024 01:48:12 PM

Document Has Been Signed on 12/18/2024 01:48 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:
12/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Daphna Garcia/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On this day, 12/18/24, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management health and safety check as a result of a complaint (15-AS-20241213155842) received by the Department. LPA met with Daphna Garcia, administrator, and informed the reason for visit. LPA spoke on the phone with Kim Fields, licensee.

LPA toured the facility inside out with the administrator.

LPA observed the following:
-at 10:30 am, disinfectant spray in the resident's room.
-at 10:40 am, unlocked garage where construction equipment, pail of paint, Raid ant and roach killer are stored.
-at 10:50 am, unlocked storage in the backyard where rake is kept.
-at 11:00 am, chemical spray tank in the backyard.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the administrator and on the phone with licensee.

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: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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Document Has Been Signed on 12/18/2024 01:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/18/2024 at 01:25 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: 12/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2024
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

-This requirement is not met as evidenced by
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Administrator locked the garage, storage and chemical spray tank.

In addition, administrator to in-service the staff and submit proof by 12/19/24.
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-Based on observation, the licensee did not comply with the section above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: unlocked garage; unlocked storage; chemical spray tank in the backyard
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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: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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