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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200764
Report Date: 11/19/2021
Date Signed: 11/19/2021 05:58:22 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
11/12/2021 and conducted by Evaluator Grace Luk
COMPLAINT CONTROL NUMBER: 15-AS-20211112092305
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: 5DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Goodluck Ndefungo, Administrator/LicenseeTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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P & I money was not available to clients.
Facility did not have an accurate staff schedule.
Facility has staff that does not have fingerprint clearance.
INVESTIGATION FINDINGS:
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On 11/19/2021 at 8:48AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Administrator/Licensee, Goodluck Ndefungo and informed him about the allegations.

During the course of investigation, LPA interviewed clients, staff, and complainant. LPA reviewed client's P & I log, staff schedule, and Guardian staff roster.

Interview with staff revealed that no cash was kept at the facility for clients. Record review indicated that client's P & I money was in a shared account with the facility.

LPA observed the staff schedule does not reflect the staff on duty for the day. According to the schedule, S4 was scheduled to work from 6am-2pm, but was not present during LPA's visit.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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 5
Control Number 15-AS-20211112092305
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: 11/19/2021
NARRATIVE
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Interview with staff reviewed that S2 have been working at the facility for 3-4 months and S3 was alone with 3 clients for 2 days in November. LPA observed from Guardian roster that S2 was not fingerprint cleared and S3 was not on the roster. LPA was not able to find S3 in the Guardian system. Staff stated that S3 is not a staff and does not have fingerprint clearance.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/12/2021 and conducted by Evaluator Grace Luk
COMPLAINT CONTROL NUMBER: 15-AS-20211112092305

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: 5DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Goodluck Ndefungo, Administrator/LicenseeTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Clients were left unattended.
Perishable foods were short.
INVESTIGATION FINDINGS:
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On 11/19/2021 at 8:48AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Administrator/Licensee, Goodluck Ndefungo and informed him about the allegations.

During the course of investigation, LPA interviewed clients, staff, and complainant. Interview with clients revealed that there's always 1 staff present at the facility. LPA observed 1 staff present during inspection. LPA toured the facility and observed facility has 2-day perishable and 7-day nonperishable food supplies during inspection.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20211112092305
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: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2021
Section Cited
CCR
85072(b)(7)
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Personal Rights.
To possess and control his/her own cash resources.
This Requirement is not met as evidence by:
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Licensee has agreed to have cash resources available to client. Licensee will show picture proof of cash resources at the facility by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having cash resources available to client which poses a potential personal rights violation to the persons in care.
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Type B
11/29/2021
Section Cited
CCR
85066(b)
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Personnel Records.
A dated employee time schedule shall be developed at least monthly...
This requirement is not met as evidence by:
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Licensee has agreed to update the staff schedule and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by having an inaccurate staff schedule which poses a potential health and safety risk to the persons in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20211112092305
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: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2021
Section Cited
CCR
80019(e)(1)
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Criminal Record Clearance.
Obtain a California clearance or a criminal record exemption as required by the Department or...
This requirement is not met as evidence by:
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Licensee will submit a written statement that all current (S2 & S3)/future employees will be fingerprint cleared prior to working at the facility and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by having uncleared persons working at the facility which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $700 is being assessed.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5