<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200472
Report Date: 11/13/2024
Date Signed: 11/13/2024 04:59:11 PM

Document Has Been Signed on 11/13/2024 04:59 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:NATIVITY CARE HOME, INC.FACILITY NUMBER:
019200472
ADMINISTRATOR/
DIRECTOR:
MINNIE BAGAOISANFACILITY TYPE:
735
ADDRESS:4441 POMPONI STREETTELEPHONE:
(510) 509-7811
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Minnie Bagaoisan, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:15 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 11/13/2024 at 1:00 PM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Minnie Bagaoisan, and explained the purpose of the visit. Administrator certificate is current and Administrator number is 6012277735. The facility’s fire clearance was approved for all six (6) ambulatory.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 3 bedrooms are occupied by the clients and 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in was measured at 113.5 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene products was available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were tested and observed in operating condition during visit. Fire extinguisher was last serviced on 03/01/2024. First aid kit was observed to be complete. Fire drill was last conducted on 11/01/2024.

At 1:23 PM, 5 of clients records were reviewed. At 2:16 PM, 4 staff records were reviewed and 4 of 4 have current first aid training and 3 of 4 associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed client's medications.

Continue to LIC809C...
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785
DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: NATIVITY CARE HOME, INC.
FACILITY NUMBER: 019200472
VISIT DATE: 11/13/2024
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
Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/21/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan
Drivers License/ Registration

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 2:30 PM, S2 did not have fingerprint clearance in Guardian.

At 2:45 PM, C1 did not have doctor's order for PRN medications.

*The total amount of civil penalties assessed on today's date is $500.00 for S2 not being fingerprint cleared.*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. 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 the appeal rights, LIC421BG, and the report were provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia ManaloTELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/13/2024 04:59 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2024 at 04:26 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

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 by not having S2 fingerprint cleared on Guardian out which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Administrator agrees to remove S2 from the schedule until S2 is fingerprint cleared. Administrator will notify CCLD once S2 is cleared. Immediate Civil Penalty Assessed for $500.00 today.
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
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME:Patricia Manalo
TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/13/2024 04:59 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2024 at 04:26 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

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 by not having a doctor's order for C1's OTC medications which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
1
2
3
4
By POC date, Administrator will submit doctor's order for C1's OTC medications.

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
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME:Patricia Manalo
TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4