<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200957
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:03:31 PM

Document Has Been Signed on 04/24/2023 04:03 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:
(925) 296-0128
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 4DATE:
04/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver Estrella TiangsingTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 11:00 AM on 04/24/2023, Licensing Program Analyst (LPA) J Sampair arrived unannounced for a complaint visit.

While conducting the complaint inspection, LPA observed 2 deficiencies, 1 Type-A and 1 Type-B (refer to LIC809-D for details).

Exit interview conducted with Caregiver Estrella Tiangsing.

LPA sent copy of this report provided via email to Administrator Norberto Geronimo.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/24/2023 04:03 PM - It Cannot Be Edited


Created By: James Sampair On 04/24/2023 at 02:48 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: IMMACULATE HOME AT WALNUT
FACILITY NUMBER: 079200957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2023
Section Cited
CCR
87705(f)(1)

1
2
3
4
5
6
7
87705 CARE OF PERSONS WITH DEMENTIA(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Caregiver locked drawer during inspection
8
9
10
11
12
13
14
Based on observation at 2:35 PM, the licensee did not comply with the section cited above at the kitchen knife drawer that was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/24/2023 04:03 PM - It Cannot Be Edited


Created By: James Sampair On 04/24/2023 at 03:03 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: IMMACULATE HOME AT WALNUT
FACILITY NUMBER: 079200957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2023
Section Cited
CCR
87705(h)

1
2
3
4
5
6
7
87705 CARE OF PERSONS WITH DEMENTIA: (h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
On or before due date, Licensee shall notify LPA that ALL non-working gates (self-closing and not self-closing) in the exterior of the facility have been repaired.
8
9
10
11
12
13
14
Based on observation at 2:45 PM, the licensee did not comply with the section cited above for 2 of the 2 gates, which pose a potential risk to the health, safety or personal rights to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3