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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200957
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:01:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2022 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221220091645
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: 4DATE:
04/24/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Norberto GeronimoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Resident was physically abused while in care
Staff physically restrained resident
INVESTIGATION FINDINGS:
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At 11:00 AM on 04/24/2023, Licensing Program Analyst (LPA) J Sampair arrived unannounced for a complaint visit and explained purpose of the visit to staff member Estrella Tiangsing, who called Administrator Norberto Geronimo, who arrived at approximately 11:45 AM.

During the investigation, the LPA conducted a health and safety inspection of the facility inside and outside and collected resident R1 and facility documentation. The Investigation Bureau (IB) conducted interviews of the Complainant and R1. The LPA then reviewed IB interviews, reviewed the documentation collected, and interviewed the Administrator and 2 staff members.

Resident was physically abused while in care
No evidence was collected from the IB interviews, LPA interviews, nor facility or R1 records provided any proof that R1 was physically abused while in care.

(Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20221220091645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/24/2023
NARRATIVE
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(...Continued from 9099-C)

Staff physically restrained resident
No evidence was collected from the IB interviews, LPA interviews, nor facility or R1 records provided any proof that R1 was physically restrained while in care.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur; therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2