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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200764
Report Date: 07/19/2023
Date Signed: 07/19/2023 03:44:39 PM

Document Has Been Signed on 07/19/2023 03:44 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
E BAY DELTA AC/SC, 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: 4DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Stella Mushi, CaregiverTIME COMPLETED:
02:50 PM
NARRATIVE
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On 07/19/2023 Licensing Program Analysts (LPAs) L. Alexander and L. Hall conducted an unannounced Case Management visit due to administrator's absence. LPAs met with Caregiver, Stella Mushi, and explained the purpose of the visit.

Upon arrival LPAs were informed that the Administrator, Goodluck Ndefungo was out of the country.

LPAs reviewed all 4 clients files and all files were incomplete. LPAs requested P & I. Staff 1 (S1) was not able to provide P & I. S1 stated owner has P & I for clients. LPAs reviewed safeguarded cash resource documents and the only document that was current was for Client 4 (C4).

The following deficiencies were observed:
  • At 1:25pm, LPAs observed facility's administrator has not been present for months.
  • At 1:45pm, LPAs observed all four (4) clients' files were incomplete.


Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEEMA HAVEN HOME
FACILITY NUMBER: 079200764
VISIT DATE: 07/19/2023
NARRATIVE
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Continued from LIC809.
  • At 2:00pm, LPA observed record of client's safeguarded cash resources for three (3) of four (4) clients was not current. And S1 was not able to provide monies for clients.


The deficiencies was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/19/2023 03:44 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/19/2023 at 02:35 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: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2023
Section Cited
CCR
80070(a)

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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidence by:
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Licensee agreed to complete client files and have them available for review the CCLD by POC date.
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Based up LPA's observation and record review, the Licensee did not comply with the section cited above in having client records current and available to review, which poses a potential health and safety risk for person in care.
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Type B
07/26/2023
Section Cited
CCR85064(f)

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85064 (f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065... in compliance with applicable law and regulation. This requirment was not met as evidence by:
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Licensee will review regulation 85064, submit a self-certification that the regulation has been reviewed and Administrator will abide by the regulation going forward by the POC date.
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Based on LPA's observation and interview, the Licensee did not comply with the section cited above in having a backup Administrator during Administrator absence.
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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:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/19/2023 03:44 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/19/2023 at 02:45 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: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2023
Section Cited
CCR
80026(h)(1)

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80026 Safeguards for Cash Resources (h) Each licensee...maintain accurate records of accounts of cash resources...(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger...

This requirement is not met as evidenced by:
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Administrator agreed to update documents and provide cash or bank account book for ATM card, and submit photos to CCLD by POC date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having current records and cash on site for review which poses a potential health, safety or personal rights risk to 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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