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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601349
Report Date: 09/14/2022
Date Signed: 09/14/2022 06:06:56 PM

Document Has Been Signed on 09/14/2022 06:06 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, 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:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:27 PM
MET WITH:Edith SilvaTIME COMPLETED:
06:16 PM
NARRATIVE
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:Licensing Program Analyst conducted an unannounced annual inspection visit focusing on infection control. LPA was allowed entry to this home by Staff Bemar Mondiagon DSP, and Administrator Edith Silva arrive a short time later. Last fire drill was on 8/16/2022 and Administrator certificate expires on 11/30/2022.

This home is for Developmentally Disabled individuals ages 18 to 59. The (4) Clients residing at this home receive case management services provided by Harbor Regional Center. This is a single-story home with 4 bedrooms 3 bathrooms, living room, kitchen, dining area and an attached garage. Licensing annual fees are current.

The following were observed/inspected:
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· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept
· LPAs was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not has one designated isolation room as all rooms are private.
· Four client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Client rooms were not equipped with alcohol-based hand sanitizer but available throughout facility.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.

Deficiencies cited, please see 809D for details.

Exit interview conducted with staff Edith Silva and copy of report provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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
Document Has Been Signed on 09/14/2022 06:06 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/14/2022 at 05:54 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: XAVIER ADULT HOME
FACILITY NUMBER: 198601349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, the licensee did not comply with the section cited above. 2 screens need repair or replacement ] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Licensee will replair or replace wndow screens and send phot to LPA as proof by POC date.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Shower facet in one restrrom and one facet in restroom sink needs repair or replacement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Licensee will repair or replace the two facets and send proof to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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