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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601349
Report Date: 12/05/2023
Date Signed: 12/06/2023 08:54:22 AM

Document Has Been Signed on 12/06/2023 08:54 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:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Edith R SilvaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Edith R. Silva and explained the purpose for todays visit. The facility phone number is 562 929 8277.

The facility consist of 4 bedrooms 3 bathrooms, living room, kitchen, dining area, laundry area, back yard, and an attached garage.

The facility had all postings at the front entrance, bathrooms, and throughout the facility. A Pre screening area with PPE supplies was observed upon entry into the facility.

LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen. The water temperature was tested and measured 118.2-119.8 degrees F. LPA Wesley sent a copy of the infection control plan to the licensee at the time of visit.

Administrators certificate for Edith Reynoso-Silva #6010876735 expires 11/30/24.

The following deficiencies were cited in accordance to the Title 22 regulations. Appeal rights given.

Exit interview conducted.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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Document Has Been Signed on 12/06/2023 08:54 AM - It Cannot Be Edited


Created By: Nicol Wesley On 12/05/2023 at 01:30 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: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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