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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601349
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:14:00 PM

Document Has Been Signed on 01/16/2025 01:14 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:XAVIER ADULT HOMEFACILITY NUMBER:
198601349
ADMINISTRATOR/
DIRECTOR:		EDITH R SILVAFACILITY TYPE:
735
ADDRESS:13547 FLATBUSH AVETELEPHONE:
(562) 929-8277
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Edith Silva AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Fely Degala at approximately 10:11 AM and explained reason for visit. Administrator Edith Silva arrived shortly.

Facility is licensed to serve four (4) developmentally disabled adults, ages 18-59. Four can be non-ambulatory. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, kitchen, 4 client bedrooms, 3 bathrooms, laundry area, front yard, backyard, and attached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguishers which is kept in kitchen. During tour LPA observed cleaning supplies and toxic substances accessible in unlocked cupboards in laundry area deficiency cited. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 5
Document Has Been Signed on 01/16/2025 01:14 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/16/2025 at 12:49 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cleaning supplies were left unlocked and accessible to clients in laundry area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Staff locked cabinet at time of visit. Administrator will conduct training with staff and email training to LPA by POC due date.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/16/2025 01:14 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/16/2025 at 12:49 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above infection control plan was not available at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Administartor will email 9282 infection control plan to LPA by POC due date.
Type B
Section Cited
CCR
80066(b)(1)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (1) A health statement as specified in Section 80065(g)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of three staff did not have a health screening with TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Administrator will email health screening to LPA by POC due 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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/16/2025 01:14 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/16/2025 at 12:49 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above did not have emergency diaster plan available at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Administrator will email 610 D emergency disaster plan to LPA by POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: XAVIER ADULT HOME
FACILITY NUMBER: 198601349
VISIT DATE: 01/16/2025
NARRATIVE
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Three (3) staff files were reviewed and included Criminal clearance record, and CPR/training. Two (2) staff were missing health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in December of 2024. Infectious control plan and emergency disaster plan will be emailed to LPA. One (1) client was interviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Edith Silva.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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