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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200764
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:22:14 PM

Document Has Been Signed on 01/26/2024 12:22 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:
01/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Elizabeth Karobia, CaregiverTIME COMPLETED:
12:45 PM
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On 01/26/2024 at 11:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Plan of Correction (POC) visit. LPA met with Elizabeth Karobia, Caregiver, and explained the purpose of the visit. Elizabeth phoned designated Administrator, Stellah Mushi to inform. LPA phoned Licensee/Administrator, Goodluck Ndefungo and left message to call back. Goodluck Ndefungo is out of the country.

LPA conducted a Case Management visit on 12/21/2023 and cited facility.

Facility has the following deficiencies that were not cleared:

  • CCR 80069(b)(c)(d)(e), LPA observed no negative TB results for C1 and no Physician's Reports for C1 and C3.
  • CCR 80068, LPA observed no Admission Agreement for C3

  • Civil Penalties for CCR 80069(b)(c)(d)(e) in the amount of $800.00 assessed immediately for the period of 01/19/2024 to 01/26/2024.
  • Civil Penalties for CCR 80068 in the amount of $800.00 assessed immediately for the period of 01/19/2024 to 01/26/2024.

Civil Penalties in the total amount of $1,600.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies 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: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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