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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200764
Report Date: 12/21/2023
Date Signed: 12/21/2023 12:21:45 PM

Document Has Been Signed on 12/21/2023 12:21 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: 3DATE:
12/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Goodluck Ndefungo, LicenseeTIME COMPLETED:
12:35 PM
NARRATIVE
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On 12/21/2023 Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit. LPA met with Licensee/Administrator, Goodluck Ndefungo, and explained the purpose of the visit.

Back on 10/30/2023 during 1-Year Annual Required Inspection, LPA L. Alexander requested updated facility documents to be submitted by 11/06/2023. Administrator, Goodluck Ndefungo, failed to submit documents by requested due date. During emails LPA observed that the Administrator does not have current Liability Insurance. During today's visit Goodluck gave LPA L. Alexander a copy of the paid receipt for liability insurance. Goodluck will send a copy of the insurance policy to LPA L. Alexander once he receives the new insurance policy number.

In addition, during the annual inspection visit, LPA L. Alexander requested that the missing files for C1 and C3 be submitted. Administrator, Goodluck stated that C1 refuses to get TB, physical exam and sign required facility documents. Goodluck says that C3 has a case manager with the county that is currently working on scheduling an appointment for C3's physical exam.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies 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: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 2
Document Has Been Signed on 12/21/2023 12:21 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 12/21/2023 at 11:18 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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
Section Cited
CCR
80069(b)(c)(d)(e)

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80069 Client Medical Assessment...(b) In ARFs , prior to accepting a client...the licensee shall obtain and keep on file...medical assessment
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Administrator agreed to obtain TB test results and Physician's Reports for C1 and C3 and will submit copies of documents to CCLD by POC due date.
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This requirement is not met as evidence by:

Based on file review and interview, licensee did not comply with the section cited above by not having TB test results and medical assessments for C1 and C3 which poses an immediate health & safety risk for persons in care.
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Type B
01/18/2024
Section Cited
CCR80068

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80068 Admission Agreements

(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any
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Administrator agreed to complete an Admission Agreement for C1 and will submit a signed copy to CCLD by POC due date.
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This requirement is not met as evidence by:

Based on file review and interview, licensee did not comply with the section cited above by not having a signed Admission Agreement on file for C1 which poses an immediate health & safety risk for 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: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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