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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200764
Report Date: 11/01/2021
Date Signed: 11/01/2021 01:44:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20211026134148
FACILITY NAME:NEEMA HAVEN HOMEFACILITY NUMBER:
079200764
ADMINISTRATOR:NDEFUNGO, GOODLUCKFACILITY TYPE:
735
ADDRESS:434 RODRIGUES AVENUETELEPHONE:
(925) 335-6428
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 2DATE:
11/01/2021
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Goodluck NdefungoTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility staff not properly handling debris at the facility & Facility grounds are unkept
Facility vehicle is in disrepair
INVESTIGATION FINDINGS:
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On 11/1/2021 at 10:25AM Licensing Program Analyst (LPA) L.Ibo arrived at the facility unannounced to investigate the above allegations. LPA knocked on facility door few times, but no one answered the door, LPA called facility Administrator NDEFUNGO, GOODLUCK, according to Administrator he is out with 2 residents to get covid19 test. LPA informed Administrator the purpose of the visit. At 1: 15PM Administrator and 2 residents arrived at the facility.

LPA conducted facility inspections inside and outside. LPA observed the following boxes of trash at the facility side yard, front lawn has electric extension wires, trash bins are full of garbage, an overturn black trash bin at the front lawn, trip hazard green water hose at the front lawn going down the side gate, an open sewer located at the side yard which is accessible to clients in care & a black plastic bag full of empty water bottles located at the right side of the front house.
...Continue LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20211026134148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEEMA HAVEN HOME
FACILITY NUMBER: 079200764
VISIT DATE: 11/01/2021
NARRATIVE
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LPA observed facility transportation vehicle windshield is cracked and bumper is missing.

Based on information obtained and LPA personal observation, the allegations are substantiated.



A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Administrator NDEFUNGO, GOODLUCK.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20211026134148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEEMA HAVEN HOME
FACILITY NUMBER: 079200764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited
CCR
80087(a)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitor..
This requirement was not met as evidenced by:
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Administrator will need to clean up all the following: boxes of trash at the facility side yard, front lawn has electric extension wires, trash bins are full of garbage, an overturn black trash bin at the front lawn, trip hazard green water hose at the front lawn going down the side gate, an open sewer located at the side yard which is accessible to clients in care & a black plastic bag full of empty water bottles located at the right side of the front house .
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Based on observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
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Proof of correction is needed on POC date. Pictures need to be sent to CCL office.
Type B
11/05/2021
Section Cited
CCR
80074(c)
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(c) Motor vehicles used to transport clients shall be maintained in a safe operating condition.

This requirement was not met as evidenced by:
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Administrator need to fix crack windshield and fix transportation vehicle bumper, proof of correction needed on POC date to be sumitted to CCL office or to LPA L.Ibo.
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Based on observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
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Administrator will send plan to fix regarding vehicle bumper, administrator said that he is planning to get a new transportation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3