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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201483
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:54:06 PM

Document Has Been Signed on 02/19/2025 01:54 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 ADULT RESIDENCE LLCFACILITY NUMBER:
019201483
ADMINISTRATOR/
DIRECTOR:		BAGAOISAN, CELSOFACILITY TYPE:
735
ADDRESS:2558 CHERRYWOOD DRIVETELEPHONE:
(510) 709-0067
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 0DATE:
02/19/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Celso Bagoisan, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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On 2/19/2025 at 12:30PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Pre-licensing Inspection. Upon arrival, LPA met with Celso Bagoisan Administrator, and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to 5 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and no slip mat . Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 70 degrees F and hot water temperature was maintained at 116 degrees F. First-aid kit was observed to be completed. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 07/15/2024.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

LPA will conduct COMP III to administrator.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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