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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 01:00:27 PM

Document Has Been Signed on 08/02/2023 01:00 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:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Umoja Terry, CaregiverTIME COMPLETED:
11:15 AM
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On 8/2/2023 at 10:00am, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct Plan of Correction (POC) visit. Fran Carey, 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.

LPA conducted a case management visit on 7/19/2023 and cited facility.

Facility has the following deficiencies that were not cleared:

  • 80070(a), LPA observed client files have not been completed.
  • 80070(g), LPA observed death report was not submitted.
  • 85064(f), LPA has not received self-certification from Administrator. Administrator still out-of-the country.
  • 80026(h)(1), LPA observed safeguards for cash resources documents have not been updated.
  • Civil Penalties for 80070(a) in the amount of $700.00 assessed immediately for the period of 7/27/2023 to 8/2/2023.

Continued on LIC809C.
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 2
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: 08/02/2023
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Continued from LIC809.
  • Civil Penalties for 85064(f) in the amount of $700.00 assessed immediately for the period 7/27/2023 to 8/2/2023.
  • Civil Penalties for 85026(h)(1) in the amount of $700.00 assessed immediately for the period 7/27/2023 to 8/2/2023.
  • Civil Penalties for 80070(g) in the amount of $700.00 assessed immediately for the period 7/27/2023 to 8/2/2023.


Civil Penalties in the total amount of $2100.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. Appeal Rights, LIC421M, 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
LIC809 (FAS) - (06/04)
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