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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200764
Report Date: 10/30/2023
Date Signed: 10/30/2023 05:49:03 PM

Document Has Been Signed on 10/30/2023 05:49 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:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eric Sydney, Direct Support Professional
Goodluck Ndefungo, Administrator		TIME COMPLETED:
06:00 PM
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On 10/30/2023 at 3:00 PM, Licensing Program Analysts (LPAs) L. Alexander and P. Watson arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Support Professional, Eric Sydney and explained the purpose of the visit. Eric called Licensee/Administrator, Goodluck Ndefungo and advised that Licensing was at the facility and Goodluck arrived approximately 30 mins later. The facility’s fire clearance was approved for 6 Ambulatory only.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which 3 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 113.5 and 112.2 degrees Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.


LIC809C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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: 10/30/2023
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LIC809 Continued....

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/14/2022. First aid kit was observed to be complete.

At 3:45 PM, 3 of 3 of clients records were reviewed. At 4:30 PM, 6 of 6 staff records were reviewed and 4 of 6 have current first aid training and associated to the facility. A sample of 3 client’s medications were reviewed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/06/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan
Liability Insurance
Updated Facility Sketch




No deficiencies were cited during this inspection. Exit interview conducted and a copy of the report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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