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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200472
Report Date: 10/22/2022
Date Signed: 10/22/2022 02:42:07 PM


Document Has Been Signed on 10/22/2022 02:42 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:NATIVITY CARE HOME, INC.FACILITY NUMBER:
019200472
ADMINISTRATOR:MINNIE BAGAOISANFACILITY TYPE:
735
ADDRESS:4441 POMPONI STREETTELEPHONE:
(510) 509-7811
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: DATE:
10/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Yolanda Bautista, CaregiverTIME COMPLETED:
02:55 PM
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On 10/22/2022 at 12:57PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Caregiver, Yolanda Bautista and explained the purpose of the visit. Administrator arrived at approximately 1:15PM.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022
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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