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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200764
Report Date: 11/01/2021
Date Signed: 11/01/2021 01:45:46 PM

Document Has Been Signed on 11/01/2021 01:45 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:NEEMA HAVEN HOMEFACILITY NUMBER:
079200764
ADMINISTRATOR:NDEFUNGO, GOODLUCKFACILITY TYPE:
735
ADDRESS:434 RODRIGUES AVENUETELEPHONE:
(925) 335-6428
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 6CENSUS: DATE:
11/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Goodluck NdefungoTIME COMPLETED:
02:15 PM
NARRATIVE
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On 11/1/2021 Licensing Program Analyst (LPA) L.Ibo conducted unannounced case management due to another visit. LPA met with Administrator Goodluck Ndefungo and explained the purpose of the visit.

LPA conducted facility inspection; LPA observed an open sewer which is accessible to clients in care. The open sewer is located as soon as someone open the side gate of the facility which poses danger to health and safety of clients in care.

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/01/2021 01:45 PM - It Cannot Be Edited


Created By: Leslie Ibo On 11/01/2021 at 11:39 AM
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: 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
11/03/2021
Section Cited
CCR
80072(a)(2)

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80072 Personal Rights (a) Except for children’s residential facilities, each client...
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
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Adminitrator will need to come up with a plan on how to make the opening inaccesible to clients in care while the Adminsitrator is waiting for a permanent fix. Proof of POC needed by POC date 11/3/2021.
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Based on observation, the licensee did not comply with the section cited above, LPA observed open sewer is located as soon as someone open the side gate of the facility which poses danger to health and safety of clients in care which poses a potential health, safety or personal rights risk to persons in care.
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Submit a plan to LPA L.Ibo by 11/3/2021.

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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: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


LIC809 (FAS) - (06/04)
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