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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 03:51:34 PM

Document Has Been Signed on 07/19/2023 03:51 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:
02:50 PM
MET WITH:Stellah Mushi, CaregiverTIME COMPLETED:
04:00 PM
NARRATIVE
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On 07/19/2023 Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct a Case Management visit to follow-up on a death report that was submitted on a Special Incident Report (SIR) received by Community Care Licensing on 03/07/2023. LPAs met with Caregiver, Stellah Mushi and explained the purpose of the visit.

SIR that was submitted indicated Client 1 (C1) passed away on 03/05/2023 with an unknown cause of death. LPAs spoke with Staff 1 (S1) and was not able obtain any additional information regarding C1's death. LPA's reviewed C1's file and did not observe a death report or death certificate.

During today's visit LPAs collected a copy of the following documents:

Physician's Report
Admission Agreement
Addendum to ISP
Life Insurance Policy

LIC809-C Continued....
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)
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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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LIC 809 Continued...

LPA's requested the following documents to be submitted to CCLD by 7/24/2023.

Record of Client's Safeguarded Cash Resources
Death Report
Death Certificate
Appraisal Needs and Services
Case/Progress Notes

The following deficiency was observed:
  • At 3:10pm, LPA's observed C1's file did not obtain death certificate or death report.


The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to submit proof of correction (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)
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Document Has Been Signed on 07/19/2023 03:51 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 07/19/2023 at 03:18 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(g)

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80070(g) (g) Original client records...retained for at least three years following termination of service to the client. This requirement was not met as evidenced by:
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Licensee agreed to submit death report to CCLD by POC due date.
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Based on LPA's record review the Licensee did not comply with the section cited above in having documents retained after termination of service. Which poses a health and safety risk to clients 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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