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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200957
Report Date: 09/18/2023
Date Signed: 09/18/2023 04:44:55 PM

Document Has Been Signed on 09/18/2023 04:44 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: 6DATE:
09/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Eileen CarreonTIME COMPLETED:
05:00 PM
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On 09/18/2023 at 02:00 PM, 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 informed Licensee Norberto Geronimo of the LPA's arrival at the facility.

Licensees Norberto Geronimo and Eileen Carreon were present during the inspection. During this visit, the LPA inspected the facility inside and outside and reviewed personnel and resident files. Facility is safe and well maintained. Residents are safe and clean. The staff are caring and well trained.

The annual inspection is complete.

No citations issued during visit.

LPA conducted an exit interview with Administrator Norberto Geronimo and sent a copy of this report via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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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