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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200764
Report Date: 08/02/2023
Date Signed: 08/02/2023 01:04:05 PM

Document Has Been Signed on 08/02/2023 01:04 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:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Umoja Terry, CaregiverTIME COMPLETED:
01:15 PM
NARRATIVE
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On 8/2/2023 at 11:15am, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct Case Management visit. Fran Carey, Regional Center East Bay (RCEB) Case Manager also attended the visit. LPAs met with Umoja Terry, Caregiver, and explained the purpose of the visit. Administrator, Goodluck Ndefungo, was out-of-the country.

During POC visit on 8/2/2023, upon arrival LPAs observed that there were 4 RCEB clients and 1 staff at the facility. S2 arrived at facility 45 minutes after LPAs arrival. RCEB case manager observed that water is running constantly in the bathroom tub. S1 informed LPAs that C1 was admitted into the facility and AWOL'd the same day. Facility did not report to CCLD.

The following deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. 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. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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 3
Document Has Been Signed on 08/02/2023 01:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 08/02/2023 at 11:37 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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
85065.5(a)(1)

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(a) Whenever a client who relies upon others...(1)For Regional Center clients, staffing shall be maintained...one direct care staff to three such clients.
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Another staff arrived approx. 45mins later. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited above in having sufficient staff available for clients which poses a potential health and safety risk to clients in care.
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Type B
08/09/2023
Section Cited
CCR80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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Licensee will repair the bathtub faucet in shared bathroom and submit photo to CCLD by POC date.
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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: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/02/2023 01:04 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 08/02/2023 at 12:07 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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
80061(b)(E)

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(b) Upon the occurrence... of the events... a report shall be made to the licensing... shall be submitted to the licensing agency within seven days following the occurrence... (E) Any unusual incident or client absence... or safety of any client.
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Licensee agreed to review Regulation 80061 and submit a self-certification that the regulation has been reviewed and the Licensee will abide by the regulations going forward. Licensee will submit self-certification to CCLD by POC date.
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 This requiremet was not met as evidence by:
Based on LPAs interview Licensee did not comply with the section cited above in reporting an AWOL, which poses a potential health and safety 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: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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