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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200764
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:04:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2022 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221103150711
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:
01/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stellah ChristopherTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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1. Staff does not ensure cleanliness and adequate maintenance of facility.
INVESTIGATION FINDINGS:
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On 01/13/2023, Licensing Program Analyst (LPA) J. Sampair arrived at the facility unannounced to deliver the findings of the investigation into the allegatins above. LPA met with Staff Stellah Christopher and explained the purpose of this follow up visit.

During the investigation, LPA observed garden soil on the sidewalk; tools, plywood, and wood planks in the back and sides of yard; and various broken items including chairs left inside and outside in areas accessible to clients in care that pose potential health and safety risk to persons in care.

Based on the LPA's observations, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview was conducted and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20221103150711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEEMA HAVEN HOME
FACILITY NUMBER: 079200764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
80087(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, employess and visitors.

Based on observations, the licensee did not comply with the section cited above.
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Licensee cleared deficiency on 11/22/2022 with photos provided for LPA Lori Alexander-Washington to clear citation during 11/10/2022 inspection.
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Garden soil, plywood, wood planks, shovels, and other broken items were left inside and outside of the facility in areas accessible to clients in care that pose potential health and safety risks 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2022 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221103150711

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:
01/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stellah ChristopherTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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1. Staff served resident unhealthy food that resulted in the worsening of resident's health while in care. 2. Staff did not inform resident's responsible party of change in resident's condition while in care. 3. Staff used shared medical device (glucometer) on resident while in care. 4. Staff did not adequately supervise residents while in care. 5. Staff did not ensure that a resident did not have access to a knife while in care. 6. Staff did not accurately manage resident's medications while in care. 7. Staff did not adequately manage resident's appointments while in care. 8. Staff did not ensure that facility was free from pests. 9. Staff did not meet resident's hygiene needs while in care. 10. Staff did not properly manage resident's medical equipment (test strips) while in care. 11. Staff did not ensure safety of resident's personal money while in care.
INVESTIGATION FINDINGS:
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On 01/11/2023, Licensing Program Analyst (LPA) J. Sampair arrived at the facility unannounced to deliver the findings of the investigation into the allegatins above. LPA met with Licensee Goodluck Ndefungo and explained the purpose of this follow up visit.

During the investigation, LPA reviewed records and conducted interviews of staff and residents. Based on the analysis of the data collected, the LPA found that the preponderance of evidence standard has not been met; therefore the allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove they did or did not
occur.

Exit interview was conducted and a copy of this report provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3