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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006234
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:27:09 PM

Document Has Been Signed on 11/08/2022 12:27 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NATIVITY CARE HOME LLCFACILITY NUMBER:
306006234
ADMINISTRATOR:TECSON, ALEXANDER M.FACILITY TYPE:
735
ADDRESS:8703 HARRISON WAYTELEPHONE:
(714) 752-6189
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 0DATE:
11/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Alexander Tecson TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Jerome Haley made an announced Pre-licensing visit and was greeted by Applicant Director/Administrator Alexander Tecson. Administrator (AD) Imelda Samonte was also present for the visit. Administrator Alexander Tecson has a current Administrator Certificate that expires 2/5/24. LPA Haley was pre screened and temperature checked upon entering the facility.

The facility is a single level structure with five bedrooms four rooms for the clients and one room for staff and three bathrooms. The Orange County Fire Authority granted the Fire Clearance for 4 Ambulatory clients on October 18, 2022. The initial application for an Adult Residential Facility with a capacity of four ambulatory clients was submitted to the Central Applications Bureau (CAB) on 8/17/22. Applicant Tecson and Samonte were present for the tour of the facility and the following was observed:

All client bedrooms were clean, neatly organized and equipped with the necessary requirements: bed, lamp, chair, and storage space. All bathrooms were clean, organized and hand washing signs were posted.
Hot water temperature was measured at 113.1 degrees Fahrenheit in Bathroom #1 in client Bedroom #1, 109.4 degrees Fahrenheit in Bathroom #2, and 113.0 degrees Fahrenheit in bathroom #4 in the client master bedroom.

In the hallway closet near bedrooms 2 and 3 LPA Haley observed a closet with a supply of clean linen. In the hallway closet across directly across LPA observed a locked closet with hygiene supplies, COVID supplies, and hazardous cleaning chemicals.

In the hallway near bedroom 4 and the staff bedroom LPA observed locked cabinets. The locked cabinets on top are for office supplies, Staff records, emergency PPE supplies: N95 Mask, Gowns, Gloves, and Hand Sanitizers.
Continued on LIC809 C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NATIVITY CARE HOME LLC
FACILITY NUMBER: 306006234
VISIT DATE: 11/08/2022
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A first aid kit with all the required elements was also observed. The locked cabinets below are for client records, medication storage, and medication records.

The living room area was clean and well organized. LPA observed a TV, fire place with a glass cover for safety, and several board games for the clients was observed under the television.

The garage was clean, organized, and walkways were free of clutter and tripping hazards. In the garage LPA Haley observed a washer, dryer, and above the washer and dryer were locked cabinets used storage of laundry detergents and bleach. A stationary bike, tread mill, beach ball, basketballs, and other recreational items for for the clients to enjoy was observed. The garage is used for a recreation area for the clients and in the summer time it's used for additional activities for the clients. A deep freezer and a TV will be added to the garage as well. The cabinets in the garage are for storage of an additional non-perishable food supply, emergency/disaster supplies for the clients, and other miscellaneous facility supplies.

The kitchen was clean and well organized. Knives and sharp objects are locked in a drawer next to the stove. All hazardous cleaning materials are locked under the sink. LPA Haley observed a 7 day non-perishable food supply and a 2 day supply of perishable food items. An adequate supply of fresh fruits was observed on the counter near the sink. All burners on the stove were operational. A fully charged fire extinguisher was mounted on the wall in between the dining room and kitchen.

The backyard was clean, well organized, and free of clutter. Walkways were free of tripping hazards and debris. Both side exit gates were self closing and self latching. A shaded patio area with tables and chairs was observed. No bodies of water was observed.

Smoke and carbon monoxide detectors tested operational.

LPA Haley did not observe anything that needs to be corrected. The Component III Power Point presentation was waived. At this time the facility will be recommended for licensure.

An exit interview was conducted and a copy of this report was provided to Applicant Alexander Tecson.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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