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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200472
Report Date: 07/31/2025
Date Signed: 08/07/2025 10:09:35 AM

Document Has Been Signed on 08/07/2025 10:09 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/
DIRECTOR:		MINNIE BAGAOISANFACILITY TYPE:
735
ADDRESS:4441 POMPONI STREETTELEPHONE:
(510) 509-7811
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: DATE:
07/31/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Celso/Minnie Bagaoisan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 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 1:30pm, LPA Luisa Fontanilla arrived at the facility to conduct a case management visit and met with Celso and Minnie Bagaoisan. LPA explained to both the purpose of the visit.

On 6/16/2023, LPA received an unusual incident report dated 5/23/2023 regarding Client 1 (C1) from the Regional Center of the East Bay (RCEB). The facility did not provide an incident report to CCL for this occurrence. The report provided by RCEB indicates that C1 was observed tired and sleepy and unable to respond to prompts to eat. C1 was moved to the couch when C1 started shaking, sat motionless but awake. 911 was called and C1 was transported to the hospital.

While in the hospital, C1’s father observed C1 grabbing right hand with left hand. C1’s right shoulder was swollen and C1 was unable to move it. C1’s father requested the doctor for an x-ray. Results showed C1 sustaining right glenohumeral dislocation and a fracture at the proximal humerus.
On 5/26/2023, C1 needed to undergo immediate surgery to repair the right shoulder dislocation.

During the course of investigation, the Department interviewed clients and staff. Two clients confirmed witnessing C2 pulling C1’s arm while C1 was in the bathroom at around 1900 hours. C3 states Staff 1 (S1) was sleeping when C2 pulled C1’s arm in the bathroom.

On 9/18/2023, the Department interviewed C2. The investigator noted that C2 was excited and energetic while initially speaking with the investigator. When asked about C1 and C1’s injuries, the investigator noticed C2 became defensive and crossed arms.

continuation on Lic 809C
This is an amended copy of the report issued on 7/31/2025.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Luisa Fontanilla
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2025
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 5
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)
Page: 2 of 5
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: 07/31/2025
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
S1 works from 0800 until 1700 and states that clients are checked 2x during the shift, once in the morning and once in the evening. S1 would assist C1 with Activities of Daily Living (ADLs). All the other clients are independent. S1 helps C1 up the stairs and down. S1 supervises C1 with showers and brushing of teeth. After the shift, S1 would make sure all doors are locked and retreats to the bedroom. S1 did not help clients unless they needed supplies like toothpaste.
One staff person, co Administrator Celso Bagaoisan works from 01800 until 0600. Checks are only conducted once during the 12-hour shift.

C1’s Individual Program Plan (IPP) indicates C1 needs verbal prompting for each step to complete brushing C1’s teeth. C1 is nonverbal and would need a reminder to leave the bathroom when done. C1 is at risk for injury if not supervised in any setting.

After the Administrator was made aware by the clients about the incident, on an unknown date, she stood next to C1 while she pointed at each client and asked C1 who had hurt C1. C1 pointed to all of the clients and returned to point at C2. Administrator asked C2 later, but C2 denied it.

The Administrator said C2 gets easily upset, pounds on the table and yells loudly. She has never seen C2 harming the other clients. When C2 is upset, staff are startled but do not engage with C2 to prevent C2 from “having behaviors.” Clients have reported to the Administrator that C2 touches them inappropriately and tries to give them kisses. The Administrator reminds C2 not to touch clients without their consent. C6 has even told the Administrator in front of his social worker (name unknown) that C2 makes comments like, “I wanna marry you,” and kisses C6’s hand.

The Administrator stated that she had reached out to RCEB, C2’s parents and C2’s social worker multiple times in the past to address C2’s behaviors, but to no avail. However, despite knowledge of C2’s aggressive behaviors and C2’s actions of bothering other clients, the facility has not implemented plans to address C2’s behaviors. The Administrator admitted that staff were aware of C2’s aggressive behaviors and prior incidents of C2 bothering other clients in the home. C2 has been moved out of the facility on 4/19/2024.
A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview was conducted with the Administrator and Appeal Rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Luisa Fontanilla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/31/2025 03:34 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/31/2025 at 02:30 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2025
Section Cited
CCR
85068.3(a)

1
2
3
4
5
6
7
85068.3(a) Modifications to Needs and Services Plan
a. (a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.
This requirement is not met
1
2
3
4
5
6
7
Non-Compliance Conference (NCC) will be scheduled to address plans of correction.
8
9
10
11
12
13
14
as evidenced by: Staff have observed C2's aggressive behavior but has not updated C2's Needs and Services Plan to address C2's aggressive behavior.
8
9
10
11
12
13
14
Type A
08/01/2025
Section Cited
CCR85078(a)(1)

1
2
3
4
5
6
7
85078 Responsibility for Providing Care and Supervision
(a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
1
2
3
4
5
6
7
NCC will be scheduled to address plans of correction.
Civil penalty of $500 is assessed.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on C1’s IPP dated 2/4/2018, C1 needs verbal prompting to complete the process of brushing teeth. C1 also needs reminder to leave the bathroom whendone. There was no staff supervising the clients when C2 pulled C1’s arm resultingto C1 sustaining dislocation and fracture.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Luisa Fontanilla
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/31/2025 03:34 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/31/2025 at 02:42 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2025
Section Cited
CCR
80061(b)(1)(D)

1
2
3
4
5
6
7
80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility...

(1) Events reported shall include the following:

1
2
3
4
5
6
7
NCC will be scheduled to address concerns.
8
9
10
11
12
13
14
(D) Any injury to any client which requires medical treatment.
This requirement is not met as evidenced by: The facility did not report the incident to CCL. RCEB provided CCL the report.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Luisa Fontanilla
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5