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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601349
Report Date: 07/01/2022
Date Signed: 07/01/2022 09:49:26 AM

Document Has Been Signed on 07/01/2022 09:49 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:XAVIER ADULT HOMEFACILITY NUMBER:
198601349
ADMINISTRATOR:EDITH R SILVAFACILITY TYPE:
735
ADDRESS:13547 FLATBUSH AVETELEPHONE:
(562) 929-8277
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
07/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Demar Mondragon and Analiza MondragonTIME COMPLETED:
10:00 AM
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
Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting a case management visit to ensure that the facility is not operating over capacity.

On today's visit, LPA Rea was greeted and allowed entry into the facility by Caregiver, Demar Mondragon. LPA explained the reason for today's visit. Caregiver, Analiza Mondragon called Administrator by telephone. However, Administrator, Edith Silva was unable to come to the facility during the visit, because she was meeting with a Licensing Program Analyst at her Children's Residential Facility.

LPA Rea spoke to Ms. Silva by telephone. Ms. Silva stated that resident #5 has been relocated to a hotel. She said resident #5 will be residing at the hotel for approximately 60 days, while her facility located in Orange County is being renovated. She stated that she has submitted the information to the appropriate regional centers, including the name of the hotel and picture(s) of the room.

LPA Rea toured the facility, and observed 4 residents. Resident #1 and Resident #2 were asleep in their room(s), Resident #3 was watching television in his room, and Resident #4 had just showered and was in her room.

There were no deficiencies issued during today's visit. LPA Rea conducted exit interview, and provided a copy of the report to Ms. Mondragon.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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 1