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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200764
Report Date: 11/19/2021
Date Signed: 11/19/2021 06:01:30 PM

Document Has Been Signed on 11/19/2021 06:01 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: 5DATE:
11/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Goodluck Ndefungo, Administrator/LicenseeTIME COMPLETED:
06:15 PM
NARRATIVE
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On 11/19/2021 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Administrator/Licensee, Goodluck Ndefungo.

While LPA was conducting a complaint investigation to deliver findings, the following deficiencies were observed.

-LPA observed unlocked cleaning supplies, bleach, and paint in the garage which was accessible to clients. Licensee locked up the cleaning supplies and paint during inspection.

-LPA observed unlocked prescription medication on the counter in front of a client's room. Licensee locked the medication during inspection.

-LPA was informed that the facility did not have a surety bond and handling a client's P & I money.

-LPA was informed that 2 out of 5 client files were not available for review.

-LPA observed from a bank statement that facility commingled funds with client's funds.

-LPA observed administrator did not have the knowledge of Title 22 regulations.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were 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
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 4
Document Has Been Signed on 11/19/2021 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 11/19/2021 at 04:51 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: 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
80087(g)

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Buildings and Grounds. Disinfectants, cleaning solutions, ...and other items that could pose a danger...shall be stored where inaccessible to clients. This requirement is not met as evidence by:
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Licensee locked up the cleaning supplies and paint during inspection.

Deficiency cleared.
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Based on observation, licensee did not comply with the section cited above by having unlocked cleaning supplies and paint which poses an immediate health and safety risk to the persons in care.
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Type A
11/20/2021
Section Cited
CCR80075(k)(1)

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Health Related Services. Medication shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidence by:
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Licensee locked up the medication during inspection.

Deficiency cleared.
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Based on observation, licensee did not comply with the section cited above by having unlocked medication which poses an immediate 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/19/2021 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 11/19/2021 at 05:08 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: 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
80026(e)

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Safeguards for Cash Resources, Personal Property, and Valuables of Residents. Cash resources...of clients shall be separate...not be commingled with facility funds... This requirement is not met as evidence by:
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Licensee has agreed to withdrawl client's money and keep it locked at the facility. Licensee will send picture proof by POC date.
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Based on observation, licensee did not comply with the section cited above by commingled facility funds with client's funds which poses an immediate health and safety risk to the persons in care.
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Type B
11/20/2021
Section Cited
CCR80025(b)

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Bonding. All licensees...who are entrusted to care for and control clients' cash resources shall file...a bond issued by a surety company ... This requirement is not met as evidence by:
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Licensee will submit a written plan to obtain surety bond within a week and will send a copy to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by commingled facility funds with client's funds 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/19/2021 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 11/19/2021 at 05:15 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: 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
11/29/2021
Section Cited
CCR
80070(d)

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Client Records. All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.... This requirement is not met as evidence by:
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Licensee will have all client files at the facility by POC date and submit self certification to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by not having 2 of 5 client's file available which poses a potential health and safety risk to the persons in care.
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Type B
11/29/2021
Section Cited
CCR80064(a)(3)

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Administrator - Qualifications and Duties. Knowledge of and ability to comply with applicable law and regulation.
This requirement is not met as evidence by:
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Licensee has agreed to review Title 22 and submit self certification by POC date.
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Based on observation, licensee did not comply with the section cited above by not having knowledge of regulations 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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