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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201009
Report Date: 04/01/2025
Date Signed: 04/01/2025 11:50:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/16/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250116095342
FACILITY NAME:NEEMA HAVEN HOME OAKLEYFACILITY NUMBER:
079201009
ADMINISTRATOR:NDEFUNGO, GOODLUCKFACILITY TYPE:
735
ADDRESS:4953 BELDIN LANETELEPHONE:
(925) 322-4982
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 3DATE:
04/01/2025
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Goodluck,Ndefungo,AdministratorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff fell asleep while on shift
INVESTIGATION FINDINGS:
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On 04/01/2025 at 10:05 AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver the findings for the allegation above. LPA met with administrator (ADM), Goodluck Ndefungo and explained the purpose of the visit.

During investigation, ADM stated to LPA that staff (S1) was caught sleeping while on duty. ADM conducted an internal investigation on January 15,2025 and asked S1 to leave the facility immediately until investigation was completed. On January, 2025, Driver from day program, dropped client (C1) off at the facility and needed staff’s signature for drop off. C1 went inside the facility, C1 let himself in by using his key and observed S1 sleeping. C1 went back to the van advised the driver, who then contacted C1’s Case Manager (CM). CM arrived and observed S1 sleeping, CM contacted ADM vis telephone to advise.

Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
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-20250116095342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEEMA HAVEN HOME OAKLEY
FACILITY NUMBER: 079201009
VISIT DATE: 04/01/2025
NARRATIVE
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Continued from LIC9099


CM was able to wake S1 up and decided to stay at the facility with C1 and other clients until another staff member arrived. Per ADM there were two other clients at the facility during this time. ADM stated had a conversation with S1 who did admit to sleeping after consuming alcohol. ADM explained the importance of the job working with clients in care and their needs. ADM stated S1 was terminated and asked to leave the facility on January 16, 2025.

Based on LPA observations and interview which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be SUBSTANTIATED.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (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. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250116095342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEEMA HAVEN HOME OAKLEY
FACILITY NUMBER: 079201009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2025
Section Cited
CCR
80065(k)
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80065 Personnel Requirements
(k) When regular staff members are absent, there shall be coverage by personnel capable of performing assigned tasks as evidenced by on-the-job performance.

This requirement is not met as evidenced by:
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Administrator agreed to conduct an in-service training with all staff members and provide a copy of training materials with signature page of staff participants to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in having a staff member on duty who wasn’t capable of performing assigned task as evidenced by on -the- job performance which posed a potential health, safety or personal rights 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: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3