079200961-7-9-2025-15-AS-DDOE-DJERKL-20250709130542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200961
Report Date: 07/09/2025
Date Signed: 07/09/2025 01:05:52 PM

Document Has Been Signed on 07/09/2025 01:05 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 WITHERS		FACILITY NUMBER:	079200961
ADMINISTRATOR/ DIRECTOR:	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:	07/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Renato Pundanera Caregiver.		TIME VISIT/ INSPECTION COMPLETED:	01:20 PM

NARRATIVE

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On 07/09/2025 at 10:00 AM, Licensing Program Analysts (LPAs) David and Andrew Christy arrived unannounced to conduct a 1-Year Required inspection. LPAs met with Caregiver, Renato Pundanera, and explained the purpose of the visit. Norberto Geronimo, Administrator was notified by phone call of visit.

LPAs toured the facility with caregiver 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 were observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPAs 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 140 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 12/18/2024. Emergency Disaster Plan was posted. First aid kit was observed to be complete. Earthquake and fire drill last conducted on 06/28/2025.

LPAs reviewed six (6) resident files, and five (5) staff files; all are found to be complete.

LPAs observed the following deficiencies:

At 10:22 AM, LPAs measured the hot water in the shared bathroom at 140 degrees Fahrenheit.

Continued on LIC809C.

Bennett Fong	TELEPHONE: (510) 286-4201
David Doidge	TELEPHONE: (916) 475-5913
	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IMMACULATE HOME AT WITHERS	FACILITY NUMBER: 079200961
	VISIT DATE: 07/09/2025

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 26 27 28 29 30 31 32	Continued form LIC809 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) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2025 01:05 PM - It Cannot Be Edited

Created By: David Doidge On 07/09/2025 at 12:49 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IMMACULATE HOME AT WITHERS	FACILITY NUMBER: 079200961
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 the hot water asset at 140 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2025
	Plan of Correction
1 2 3 4	Administrator to lower water temperature and send proof to LPA by end of day 07/10/2025

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.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (510) 286-4201

	David Doidge
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 475-5913

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC809 (FAS) - (06/04)

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