079200961-8-7-2024-15-AS-CFOR-D7WSTG-20240807140932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200961
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:09:49 PM

Document Has Been Signed on 08/07/2024 02:09 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	IMMACULATE HOME AT WITHERS		FACILITY NUMBER:	079200961
ADMINISTRATOR:	GERONIMO JR, NORBERTO G		FACILITY TYPE:	740
ADDRESS:	3151 WITHERS AVENUE		TELEPHONE:	(510) 229-0898
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	MARICEL GORREMANS, CAREGIVER		TIME COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8/07/2024 at 10:15AM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Maricel Gorremans Caregiver, and explained the purpose of the visit. Norberto Geronimo, Administrator arrived at 11:30AM. The Administrator currently holds a certificate (#7003393740) that expired on 04/15/2026 and is waiting on his renewed certificate to be mailed. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents. LPA toured the facility with Caregiver and Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of eight (8) total bedrooms which two (2) rooms are occupied by staff and four (4) bathrooms which one (1) is designated for staff use. No bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/07/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete. Earthquake and fire drill last conducted on 06/28/2024. CONTINUE ON LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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: 08/07/2024

NARRATIVE

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CONTINUE FROM LIC809

LPA reviewed five (5) resident files and three (3) staff files all complete.

LPA observed the following deficiencies:

· At 1:55pm LPA observed washing machine, 2 ladders, 3 commodes, shovel and planting pots located on the side of the home in the backyard.

LPA requested the following documents to be submitted to CCLD by 08/14/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (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. A copy of this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/07/2024 02:09 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation:(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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having washing machine, 2 ladders, 3 commodes, shovel and planters located on the side yard which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove the washing machine, 2 ladders, 3 commodes, shovel and planters by the POC date and provide the Department photo copies.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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