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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200961
Report Date: 07/01/2020
Date Signed: 07/01/2020 02:34:32 PM

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 WITHERSFACILITY NUMBER:
079200961
ADMINISTRATOR:GERONIMO JR, NORBERTO GFACILITY TYPE:
740
ADDRESS:3151 WITHERS AVENUETELEPHONE:
(510) 229-0898
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 5DATE:
07/01/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Eileen Carreon, Administrator TIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) T. White and J. Jackson conducted a televisit prelicensing inspection on this date starting at 11:00am via facetime due to shelter in place directed by the Governor. LPAs met with Administrator, Eileen Carreon.

During the televisit inspection, LPAs toured facility with Administrator including but not limited to the residents bedrooms, staff room, common areas, kitchen, and outdoor area. Residents bedrooms are equipped with the proper furniture and bedding linens. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The kitchen was observed cleaned and within compliance. Bathrooms were equipped with grab bars and non-skid mats. Living room is equipped with the proper furniture for the residents. There is a designated storage cabinets with a lock installed for cleaning supplies and knives. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was last serviced on 01/06/2020. Smoke detectors and Carbon Monoxide detector were observed throughout the facility and in working condition. Medication cabinet locked and first aid kit observed to be complete. LPA advised Administrator hot water temperature should be maintained between 105 degrees F and 120 degrees F. LPA observed a one week supply of non-perishable and 2-day perishable foods.

At 11:50am, LPAs completed Component III with Administrator. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and LPA will email a copy of report to Administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2020
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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