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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200961
Report Date: 02/11/2025
Date Signed: 02/11/2025 02:43:22 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
12/03/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20241203144934
FACILITY NAME:IMMACULATE HOME AT WITHERSFACILITY NUMBER:
079200961
ADMINISTRATOR:GERONIMO JR, NORBERTO GFACILITY TYPE:
740
ADDRESS:3151 WITHERS AVENUETELEPHONE:
(510) 229-0898
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 6DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Norberto Geronimo, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility Staff are not assisting with toileting
Facility Staff are restricting meals
INVESTIGATION FINDINGS:
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On 2/11/2025 at 2:00PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator Norberto Geronimo.

On the allegation: Facility Staff are not assisting with toileting
Interviews with staff indicated that R1 was receiving assistance with toileting. S1 stated that they did provide a commode in the resident’s room for nighttime to reduce the risk of falling and staff assisted with toileting and changing during the day.

On the allegation: Facility Staff are restricting meal
LPAs interviewed Administrator, and clients. Based on interviews it was stated that the facility provides residents with snacks. If ambulatory residents may go to the kitchen to get one of the many snack options and if a resident is non-ambulatory, they may request a snack from the staff.
Continued on 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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-20241203144934
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 WITHERS
FACILITY NUMBER: 079200961
VISIT DATE: 02/11/2025
NARRATIVE
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... Continued from 9099

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

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2