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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200957
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:37:36 AM

Document Has Been Signed on 12/22/2022 11:37 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:IMMACULATE HOME AT WALNUTFACILITY NUMBER:
079200957
ADMINISTRATOR:GERONIMO JR, NORBERTO GFACILITY TYPE:
740
ADDRESS:435 WALNUT AVENUETELEPHONE:
(925) 296-0128
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
12/22/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Norberto Geronimo and Eileen CarreonTIME COMPLETED:
11:00 AM
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On 12/22/2022, Licensing Program Analysts (LPAs) J. Sampair and G. Luk arrived unannounced to conduct a health and safety check as a result of a Priority 2 complaint. LPAs met with Licensees, Norberto Geronimo and Eileen Carreon.

LPAs toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, garage and outdoor area. Facility temperature was maintained at 70.9 degrees F. Hot water temperature was measured at 118 degrees F in kitchen sink. 7-days of non-perishable and 2-days of perishable food supplies were sufficient. Resident medications were kept locked in the cabinet. Smoke and Carbon monoxide detectors tested and were functional. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 12/22/2021. There are no accessible bodies of water observed..

No citations issued.

Exit interview conducted. A copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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