<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201009
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:53:57 PM

Document Has Been Signed on 05/27/2022 03:53 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 0DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Goodluck Ndefungo, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/27/2022 3:00PM, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with Administrator Goodluck Ndefungo. Facility has census of 0. Facility still on the process of vendorization from RCEB. LPA requested from Administrator to inform LPA once they admit new clients.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. No bodies of water observed. LPA observed Administrator cleaning and organizing the facility, Administrator stated that he is getting ready for Regional Center of East Bay (RCEB) visit for vendorization.

LPA provided technical assistance to post visitor policy on the front entrance. There is one central entry point for universal screening for future staff, residents and visitors. LPA provided technical assistance to have sign-in policy, thermometer and hand sanitizer at screening station. Facility need to add cough/sneeze etiquette, social distancing and hand washing posters.

LPA requested from Administrator to send picture of the facility’s garage, kitchen, rooms and common area after the cleanup by May 31, 2022.

No deficiency cited during the visit.

Exit interview conducted. Copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1