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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 01:54:46 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 LLC
FACILITY NUMBER:
019201483
ADMINISTRATOR/
DIRECTOR:
BAGAOISAN, CELSO
FACILITY TYPE:
735
ADDRESS:
2558 CHERRYWOOD DRIVE
TELEPHONE:
(510) 709-0067
CITY:
UNION CITY
STATE:
CA
ZIP CODE:
94587
CAPACITY:
6
CENSUS:
0
DATE:
02/19/2025
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:
Celso Bagoisan, Administrator
TIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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A Comp III associated with Pre-Licensing Inspection done on 2/19/2025 at 1:35 PM was conducted by Licensing Program Analyst (LPA) K. Nguyen. Comp III was attended by Celso Bagoisan Applicant.
LPA concluded Comp III.
No citation made during this visit. 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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