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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201009
Report Date: 05/10/2023
Date Signed: 05/10/2023 11:32:07 AM

Document Has Been Signed on 05/10/2023 11:32 AM - 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: 3DATE:
05/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Umonja Terry, Direct Support ProfessionalTIME COMPLETED:
11:40 AM
NARRATIVE
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On 5/10/2023 at 10:30AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Umonja Terry, Direct Support Professional and explained the reason for the visit.

When LPA L. Hall was conducting a complaint investigation (15-AS-20230501140731) on 5/10/2023. Upon arrival no one was at the facility. LPA called and spoke with Staff 1 (S1) and was told someone will arrive shortly. As LPA was returning to the vehicle a client Client 2 (C2) walked up and stated to LPA that he is left at the home but has the code for the door. C2 went inside and LPA went back to vehicle. Staff 2 (S2) arrived at 10:00AM with other clients. LPA requested files for staff and clients, S2 was not able to provide those files for LPA to reviews. S2 stated Administrator was out-of-the country and has been gone for approximately one (1) month.

The following defencies were observed:

-At 9:40AM, LPA observed C2 was left at facility unsupervised.
-At 10:05AM, LPA observed Administrator was not available and did not have a backup.
-At 10:15AM, LPA observed that S2 was not able to provide staff or client files for review.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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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: 05/10/2023
NARRATIVE
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Continued from LIC809.

Deficiencies are 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 this report, LC421M and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/10/2023 11:32 AM - It Cannot Be Edited


Created By: Laura Hall On 05/10/2023 at 10:41 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
1548(c)(3)

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1548 Civil penalties... (c) The department shall assess an immediate civil penalty of... ($500) per violation... ($100) for each day the violation continues... (3) Absence of supervision, as required by statute or regulation. This requirement was not met as evidence by:
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Direct Support Professional arrived 30 minuets after client was alone. Deficiency cleared during visit.
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Based on LPA's observation and interview, the Licensee did not comply with the section above in having supervision for C2 at the facility, which poses an immediate health and safety risk for persons in care.
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Type B
05/17/2023
Section Cited
CCR80066(a)

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80066 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by:
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Licensee agreed to complete personnel files and have them available for review the CCLD by POC date.
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Based up LPA's observation and interview, the Licensee did not comply with the section cited above in having personnel records current and available to review, which poses a potential health and safety risk for person 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 11:32 AM - It Cannot Be Edited


Created By: Laura Hall On 05/10/2023 at 10:54 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited
CCR
80070(a)

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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidence by:
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Licensee agreed to complete client files and have them available for review the CCLD by POC date.
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Based up LPA's observation and interview, the Licensee did not comply with the section cited above in having client records current and available to review, which poses a potential health and safety risk for person in care.
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Type B
05/17/2023
Section Cited
CCR85064(f)

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85064 (f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065... in compliance with applicable law and regulation. This requirment was not met as evidence by:
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Licensee will review regulation 85064, submit a self-certification that the regulation has been reviewed and Administrator will abide by the regulation going forward by the POC date.
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Based on LPA's observation and interview, the Licensee did not comply with the section cited above in having a backup Administrator during Administrator absence.
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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