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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201009
Report Date: 05/26/2023
Date Signed: 05/26/2023 04:37:34 PM

Document Has Been Signed on 05/26/2023 04:37 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: 2DATE:
05/26/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Agatha Warance, Direct Support StaffTIME COMPLETED:
04:55 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 5/26/2023 at 03:20PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Agatha Warance, Direct Support Staff, and explained the purpose of the visit. Administrator, Goodluck Ndefungo, was out-of-the country.

LPA conducted a case management visit on 5/10/2023 and cited facility.

Facility has the following deficiencies that were not cleared:

  • 80070(a), LPA observed client files have not been completed.
  • 80066(a), LPA observed staff files have not been completed.
  • 85064(f), LPA has not received self-certification from Administrator. Administrator still out-of-the country.
  • Civil Penalties for 80070(a) in the amount of $900.00 assessed immediately for the period of 5/18/2023 to 5/26/2023.
  • Civil Penalties for 85066(a) in the amount of $900.00 assessed immediately for the period of 5/18/2023 to 5/26/2023.
  • Civil Penalties for 85064(f) in the amount of $900.00 assessed immediately for the period 5/18/2023 to 5/26/2023.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/26/2023
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
26
27
28
29
30
31
32
Continued from LIC809.

Civil Penalties in the total amount of $2700.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2