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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200472
Report Date: 06/23/2023
Date Signed: 06/23/2023 10:45:11 AM

Document Has Been Signed on 06/23/2023 10:45 AM - 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: 6DATE:
06/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Minnie BagaoisanTIME COMPLETED:
11:00 AM
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On this day at around 9:15 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit in connection with an incident reported by Regional Center of the East Bay (RCEB) when Client 1 (C1) sustained fracture in the upper arm. LPA met with Administrator Minnie Bagaoisan. LPA explained to Bagaoisan the purpose of visit.

During the visit, LPA obtained the following records for C1: Lic 601, SIR dated May 23, 2023, amended SIR, Seizure Chart, IPP and Physician's Report.

LPA will make a referral to IB to conduct investigation.

A copy of this report was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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