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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201356
Report Date: 08/06/2025
Date Signed: 08/06/2025 02:12:30 PM

Document Has Been Signed on 08/06/2025 02:12 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 BAYFACILITY NUMBER:
079201356
ADMINISTRATOR/
DIRECTOR:		GITHII, GEORGE NJUNGEFACILITY TYPE:
735
ADDRESS:1914 MINER AVENUETELEPHONE:
(925) 335-6428
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 0DATE:
08/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Good Luck Ndefungo, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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At approximately 9:45AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection, there was no one at the facility. LPA attempted to contact the Administrator which was not available. LPA was able to speak with the Licensee Good Luck Ndefungo who arrived at the facility at 12:00pm and informed LPA the facility is being rented as an Airbnb.

LPA conducted a tour of the facility and observed the following: the facility is not clean and sanitary, a case of water is obstructing the front door. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins are not secure but the facility has no clients. LPA did not witness sufficient supply of hygiene products, paper products, and linens available for resident use.

Administrator's Certificate# (6064355735) was current with an expiration date of 09/01/2025.

Facility's fire extinguishers were last inspected 08/26/2024. Smoke detectors and carbon monoxide detectors were tested and operational. Hot water temperatures in facility is not within Title 22 regulations of 105 to 120 degrees Fahrenheit, hot water temperature is 1371.

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/06/2025 02:12 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/06/2025 at 01:01 PM
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 BAY
FACILITY NUMBER: 079201356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 by not having the home clean and sanitary which poses a potential health and safety or risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
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Licensee agreed to clean the facility and provide pictures of the facility to the department by the POC date
Type B
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by operating an Airbnb in the facility which is beyond the conditions and limitations specified on the license, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/11/2025
Plan of Correction
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Licensee agreed to clear the home, clean and no longer rent the facility through the Airbnb service, submit a copy of a canceled contract, also Licensee and Administrator shall read and self certify that they have read and understand the regulation and submit all document to the department by the 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2025 02:12 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/06/2025 at 01:01 PM
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 BAY
FACILITY NUMBER: 079201356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, the licensee did not comply with the section cited above by not having an emergency and disaster plan available at the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
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Licensee agreed to complete a emergency and disaster plan which will be maintained at the facility and provided the department with a copy by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2025 02:12 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/06/2025 at 01:23 PM
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 BAY
FACILITY NUMBER: 079201356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088
(e) Faucets used by clients... shall deliver hot water.(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water... a hot water temperature of not less than 105 degrees F and not more than 120 degrees F. This

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 by having hot water temperature at 137.1 which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Licensee agreed to adjust the water temperature and submit a photo to the department by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


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 BAY
FACILITY NUMBER: 079201356
VISIT DATE: 08/06/2025
NARRATIVE
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CONTINUE FROM LIC 809

LPA requested the following documents to be submitted to CCLD by 06/13/2025.

· Liability Insurance and Surety Bond

· Surety Bond

· LIC500 (Personnel Record)

· LIC308 (Designation of facility Responsibility)

· LIC400 (Affidavit Regarding Client/Resident Cash Resources)

· LIC610D (Emergency Disaster Plan)

LPA observed the following deficiency:

  • At 12:20PM, LPA was informed and observed the facility is occupied with Airbnb renters.
  • At 12:22PM, LPA observed the facility is not clean and sanitary.
  • At 1:00PM, LPA observed hot water temperature in the shared clients’ bathroom was measured at 137.1 degrees Fahrenheit.
  • At 1:35PM, LPA was informed and observed the facility dose not have an emergency disaster plan available at the facility.


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.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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