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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200961
Report Date: 07/14/2021
Date Signed: 07/14/2021 01:26:25 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: 4DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carlota Caluag & Norberto Geronimo Jr. TIME COMPLETED:
01:45 PM
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On 7/14/2021 at 10:30 AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with S1 and S2. LPA spoke with administrator, at 11:15 AM , Administrator arrived at the facility and left at 1:00PM. Administrator gave authorization for S1 to sign the annual inspection reports. LPA observed 2 staff wearing face masks during visit. LPA observed 1 residents relaxing in the living room while the other 3 residents were resting in their bedrooms. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed a screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks, no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 posters were posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. LPA observed furniture spaced six feet apart for social distancing among residents in the living room.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2021
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Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 72 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Smoke and Carbon monoxide detectors were operational.

No deficiencies were observed during the infection control annual inspection.
Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC809 (FAS) - (06/04)
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