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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201009
Report Date: 07/19/2023
Date Signed: 07/19/2023 12:10:09 PM

Document Has Been Signed on 07/19/2023 12:10 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:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Agatha Warance, Direct Support ProfessionalTIME COMPLETED:
12:20 PM
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On 7/19/2023 at 11:40am, Licensing Program Analysts (LPAs), L. Hall and Lori Alexander arrived unannounced to conduct a case management visit. 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.

LPAs reviewed P & I, both clients safeguarded cash resource documents, and receipts. LPAs scanned all documents to email. Staff 1 (S1) could not explain any of the charges. LPAs did observe IPad, IPad case, trampoline, 2 tricycles, white rocking chair, 2 plastic rocking chairs outside, and brown massage chair. LPA inquired about the monthly amount each client receives for spending, due to safeguarded cash resources document for Client 1 ( C1) has not been updated since 5/28/2023 and Client 2 ( C2) has not been updated since 5/7/2023.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
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.

LIC809 (FAS) - (06/04)
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