019200472-10-18-2023-15-AS-LFOA-CWQTK5-20231018144721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200472
Report Date: 10/18/2023
Date Signed: 10/18/2023 02:47:54 PM

Document Has Been Signed on 10/18/2023 02:47 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 BAGAOISAN		FACILITY TYPE:	735
ADDRESS:	4441 POMPONI STREET		TELEPHONE:	(510) 509-7811
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6		CENSUS: 5	DATE:	10/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Minnie Bagaoisan		TIME COMPLETED:	03:15 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 this day at around 9:50 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Minnie Bagaoisan. LPA explained to Administrator the purpose of the visit. The facility is a Level 3 home vendorized by the Regional Center of the East Bay (RCEB). The facility has an approved fire clearance for 6 all ambulatory clients. During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, kitchen, common areas, backyard. The facility is a two storey building with 5 bedrooms and 3 bathrooms. Two of the five rooms are designated as staff rooms. All client rooms are located on the second level of the facility. There was one client at the facility. The Administrator and caregiver were also present during the visit. The facility was observed to be clean and odor free. There were multiple fire extinguishers observed that appeared full and were last inspected on 12/27/2023. Facility has interconnected smoke detector/carbon monoxide that were tested and functional. Medications were observed locked in a cabinet in the kitchen. Chemicals were locked in the garage. Hot water measured at 110 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Ample supply of blankets, sheets, towels and hygiene products were observed. All passageways were observed to be free from obstruction. There is a shaded area in the backyard that is being used by clients for activities. At 12:20 pm, LPA reviewed 5 client files and 2 staff files. At 1:20pm, LPA reviewed P&I money and log with Administrator. *continuation on Lic 809C*

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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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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: NATIVITY CARE HOME, INC.	FACILITY NUMBER: 019200472
	VISIT DATE: 10/18/2023

NARRATIVE

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Facility has surety bond in the amount of $2,000. However, amount of money being handled is $3,248.51.

At 1:45 pm, LPA interviewed 2 clients and 1 staff on shift.

At 1:56 pm, LPA reviewed medications and Medication Administration Record (MAR).

Deficiency is cited per Title 22 California Code of Regulations. Refer to the attached Lic 809D.

Exit interview was conducted with Administrator and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2023 02:47 PM - It Cannot Be Edited

Created By: Luisa Fontanilla On 10/18/2023 at 02:32 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: NATIVITY CARE HOME, INC.	FACILITY NUMBER: 019200472
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80025(d)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not maintaining sufficient surety bond to cover amount of money being handled at one time which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator states surety bond will be increased from $2000 to $5000 and submit proof to CCL by POC date.

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:

Yvonne Flores-Larios

LICENSING EVALUATOR NAME:

Luisa Fontanilla

LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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