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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201009
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:40:35 PM

Document Has Been Signed on 05/09/2024 12:40 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NEEMA HAVEN HOME OAKLEYFACILITY NUMBER:
079201009
ADMINISTRATOR/
DIRECTOR:		NDEFUNGO, GOODLUCKFACILITY TYPE:
735
ADDRESS:4953 BELDIN LANETELEPHONE:
(925) 322-4982
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 3DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Goodluck Ndefungo AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:54 PM
NARRATIVE
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On 05/09/2024 at 10:00am, Licensing Program Analysts (LPAs) T.Syess-Gibson and C.Fowler conducted an unannounced annual 1-Year required inspection. LPAs met with Goodluck Ndefungo, Administrator, and explained the purpose of the visit. The administrator currently holds a certificate (#6041546735) that expires on 03/21/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 106.2 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/21/2024. Emergency Disaster Plan was last posted on 04/24/2024 . First aid kit was observed to be complete.

Continued on LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/09/2024
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Continued from LIC809.

LPAs reviewed three (3) clients records and three (3) staff records, and they were current and complete. LPAs also reviewed P & I and a sample of medication.

LPA requested the following documents to be submitted to CCLD by 05/16/24.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan (last page)
· Liability Insurance and Surety Bond

LPA observed the following deficiencies:
· At 10:29AM LPAs observed broken blinds in living room
· At 10:32AM LPAs observed missing drawers and missing handles (disrepair) chest drawers in rooms #1, #2 and #3
· At 10:37AM LPAs observed broken light bulbs in the common bathroom
· At 10:40AM LPAs observed a hole in the fence in the backyard
· At 10:41AM LPAs observed a disrepair screen on bedroom window

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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. A copy of the appeal rights and this report provided.

Continue on LIC809D

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

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 12:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 05/09/2024 at 11:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NEEMA HAVEN HOME OAKLEY
FACILITY NUMBER: 079201009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having chest drawers in disrepair in clients' room, broken lighbulbs in common bathroom and a section of the backyard fence in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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Administrator agreed to fix or replace chest drawers, ightbulbs in the common restroom and the fence in the backyard and provide an email with photos to CCLD by POC date.
Type B
Section Cited
CCR
80088(b)
Furniture, Fixtures, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in a window screen in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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Administrator agreed to fix or replace window screen and provide an email with photos to CCLD by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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