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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200957
Report Date: 08/04/2023
Date Signed: 08/07/2023 12:01:33 PM


Document Has Been Signed on 08/07/2023 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:IMMACULATE HOME AT WALNUTFACILITY NUMBER:
079200957
ADMINISTRATOR:GERONIMO JR, NORBERTO GFACILITY TYPE:
740
ADDRESS:435 WALNUT AVENUETELEPHONE:
(925) 296-0128
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
08/04/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Caregiver Elizabeth Joy FernandezTIME COMPLETED:
01:15 PM
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On 08/04/2023 at 10:15 AM, Licensing Program Analyst J. Sampair arrived unannounced as a continuation of the annual inspection began on 07/19/2023. Upon entry, LPA informed Caregiver Elizabeth Joy Fernandez of the purpose of the visit. Caregiver called Licensee Eileen Carreon and informed her of the LPA's arrival at the facility.

LPA and Licensee subsequently spoke over the phone. Initially, the conversation was about the annual inspection. At approximately 10:30 AM, the Licensee shared a report from witness W1 alleging that staff member S1's had behaved in an abusive manner toward residents R1 and R2.

After that report, the LPA interviewed Licensee, W1, and W2 about S1's alleged behavior toward R1 and R2. LPA found no evidence that the behavior of S1 rose to the level of abuse and filing a complaint. Instead, S1's behavior was better handled internally, through coaching on speaking at a volume and in a manner better suited to a professional environment since this was not S1's home but rather the home of the residents living in the facility.

LPA conducted an exit interview with Caregiver Elizabeth Joy Fernandez and sent a copy of this report to Licensee via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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