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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200957
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:20:19 PM

Document Has Been Signed on 06/17/2021 03:20 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:IMMACULATE HOME AT WALNUTFACILITY NUMBER:
079200957
ADMINISTRATOR:GERONIMO JR, NORBERTO GFACILITY TYPE:
740
ADDRESS:435 WALNUT AVENUETELEPHONE:
(510) 229-0898
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Pablo Larosa, StaffTIME COMPLETED:
03:30 PM
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On 06/17/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with S1 and S2. LPA spoke with administrator who was not available during visit. Administrator gave authorization for S2 to sign the annual inspection reports. LPA observed 2 staff wearing face masks during visit. LPA observed 2 residents relaxing in the living room while the other 4 residents were resting in their bedrooms. Facility has a completed mitigation plan in place dated 03/12/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed a screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks, no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. LPA observed furniture spaced six feet apart for social distancing among residents in the living room.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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: IMMACULATE HOME AT WALNUT
FACILITY NUMBER: 079200957
VISIT DATE: 06/17/2021
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Infection control designated leader is the administrator. All staff and 5 residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 72 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged and last inspected on 05/12/21. Smoke and Carbon monoxide detectors were operational. LPA observed a written Emergency Disaster Plan dated 5/12/21 posted in the bulletin board next to the kitchen area. LPA also observed PIN 20-38-ASC posted and emergency contact information.

Updated copies of the following documents were obtained during visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies were observed during the infection control annual inspection.
Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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