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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601476
Report Date: 01/20/2022
Date Signed: 01/20/2022 02:05:00 PM



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
01/12/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220112164507
FACILITY NAME:IMMACULATE HEART RESIDENTIAL CAREFACILITY NUMBER:
075601476
ADMINISTRATOR:MARCELINA BADEOFACILITY TYPE:
740
ADDRESS:2030 TIOGA PASS WAYTELEPHONE:
(925) 755-2750
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
01/20/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marcelina Badeo, administratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility fence is in disrepair
INVESTIGATION FINDINGS:
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On 01/20/22 at 1:45PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with the administrator and delivered the findings. LPA explained the purpose of the visit with administrator.

During investigation, LPA observed missing fencing planks on the side yard. Administrator stated she has already contracted a fencing company to fix the side yard fence. LPA observed a repairman during visit fixing the other side of the fence. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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-20220112164507
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 HEART RESIDENTIAL CARE
FACILITY NUMBER: 075601476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2022
Section Cited
CCR
87303(a)
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(a) 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.
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By POC due date, Administrator agreed to submit to CCLD photos of fixed side yard fence.
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This requirement was not met as evidenced by missing wood planks on the sideyard fence which posed a potential health & safety risk to residents in care.
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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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2