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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201009
Report Date: 07/19/2023
Date Signed: 07/19/2023 12:08:15 PM

Unsubstantiated


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
05/01/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20230501140731
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: 2DATE:
07/19/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Agatha Warance, Direct Support ProfessionalTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff not providing the personal assistance and care with activities of daily living as necessary to meet the client's
INVESTIGATION FINDINGS:
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On 7/19/2023 at 11:00am, Licensing Program Analysts (LPAs), L. Hall and Lori Alexander arrived unannounced 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 the interview Staff 1 (S1) stated that staff does clients laundry and changes bed linens once a week or whenever is needed. S1 also stated C1 is bathed every day. LPA observed Client 1 (C1) during the visit. C1 had injuries to his head and seemed to be well-groomed. S1 stated C1 will not wear his helmet. LPA toured the facility with S1 and observed washing machine in use. And the facility sanitary.

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

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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 2
Control Number 15-AS-20230501140731
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: 07/19/2023
NARRATIVE
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Continued from LIC9099.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2