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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200957
Report Date: 08/04/2023
Date Signed: 08/07/2023 12:03:10 PM

Document Has Been Signed on 08/07/2023 12:03 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
OAKLAND ASC, 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:
08/04/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Norberto GeronimoTIME COMPLETED:
04:15 PM
NARRATIVE
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On 08/04/2023 at 10:15 AM, Licensing Program Analyst J. Sampair arrived unannounced as a continuation of the annual inspection began on 07/19/2023. Upon entry, LPA informed Caregiver Elizabeth Joy Fernandez of the purpose of the visit. Caregiver called Licensee Eileen Carreon and informed her of the LPA's arrival at the facility.

During this visit, the LPA inspected the facility's physical plant. The annual inspection is not complete.

1 Type-B citation was issued during visit (for details refer to LIC809-D).

LPA conducted an exit interview with Caregiver Elizabeth Joy Fernandez and sent a copy of this report to Licensee via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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 2
Document Has Been Signed on 08/07/2023 12:03 PM - It Cannot Be Edited


Created By: James Sampair On 08/04/2023 at 04:01 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: IMMACULATE HOME AT WALNUT
FACILITY NUMBER: 079200957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 in the kitchen, where the microwave fan is not operating correctly to keep the kitchen smoke-free, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2023
Plan of Correction
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Licensee shall have the microwave and the fan repaired so that they operate correctly to remove smoke from cooking.
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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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