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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201009
Report Date: 06/30/2023
Date Signed: 06/30/2023 11:17:05 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
06/28/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230628145254
FACILITY NAME:NEEMA HAVEN HOME OAKLEYFACILITY NUMBER:
079201009
ADMINISTRATOR:NDEFUNGO, GOODLUCKFACILITY TYPE:
735
ADDRESS:4953 BELDIN LANETELEPHONE:
(925) 335-6428
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 3DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Agatha Warance, Direct Support ProfessionalTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff did not provide transportation to resident in a timely manner.
INVESTIGATION FINDINGS:
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On 6/30/2023 at 10:00am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct an initial 10-day complaint investigation visit and to deliver complaint findings for the allegation above. LPA met with Agatha Warance, Direct Support Professional (DSP) and explained the reason for the visit. Administrator, Goodluck Ndefungo, is still out-of-the country.

During the course of the investigation LPA interviewed two (2) staff and the Reporting Party. During interview Staff 1 (S1) stated that staff did not have transportation to pick up Client 1 (C1). Staff 2 (S2) who was not associated to the facility at the time of the incident on 4/25/2023, stated that he picked up C1 due to it was an emergency. S2 also stated he was at the other facility and was asked to pick up C1, that was the reason why it took so long to pick up C1.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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-20230628145254
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 OAKLEY
FACILITY NUMBER: 079201009
VISIT DATE: 06/30/2023
NARRATIVE
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Continued from LIC9099.

Based on LPA interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230628145254
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 OAKLEY
FACILITY NUMBER: 079201009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2023
Section Cited
CCR
80072(a)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
This requirement was not met as evidence by:
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Staff will implement a plan to transport residents in a timely manner and submit plan to CCLD by POC date.
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Based on LPAs interviews the facility did not comply with the section above in transporting client in a timely manner which poses a potential health and safety risk 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: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3