198601349-5-23-2025-28-AS-RORN-DH5KBA-20250529074510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601349
Report Date: 05/23/2025
Date Signed: 05/23/2025 05:16:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250422154441

FACILITY NAME:	XAVIER ADULT HOME		FACILITY NUMBER:	198601349
ADMINISTRATOR:	EDITH R SILVA		FACILITY TYPE:	735
ADDRESS:	13547 FLATBUSH AVE		TELEPHONE:	(562) 929-8277
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	4	CENSUS: 4	DATE:	05/23/2025
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Edith Silva - Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff does not ensure resident's hygiene needs are being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent visit to deliver complaint investigation findings on the above mentioned allegation. LPA met with Administrator Edith Silva and explained the purpose of the visit.

Investigation consisted of the following:

During the initial visit conducted on 4/24/25 LPA obtained copies of relevant documents within C1's file including: Most Recent IPP, Physician Report, Recent Doctor Visit Summaries, Bowel Movement Record from Jan 2025-April 2025. LPA toured C1's room, observed incontinence supplies, and interviewed 3 Staff / 2 Clients. On 5/22 LPA interviewed 1 witness (W1). During todays visit LPA interviewed 1 Staff, 1 Client and delivered findings on above allegation.
(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250422154441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: XAVIER ADULT HOME	FACILITY NUMBER: 198601349
	VISIT DATE: 05/23/2025

NARRATIVE

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The investigation revealed the following:
Allegation: Staff does not ensure resident's hygiene needs are being met.
It is alleged that for the past 6 months staff at facility would not clean C1 after changes with bowel movements. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that they always assist the clients with their changes and using restroom and none of the clients are left soiled or denied assistance. LPA interviewed 3 clients and 3 out of 3 clients denied the above allegations and stated that they are provided with assistance and have observed staff helping clients with hygiene needs. C1 stated the staff do assist with cleaning after toileting however C1 feels that due to recent health decline and inability to clean themself properly staff are getting frustrated with them. LPA toured facility and sufficient amount of hygiene products were observed, clients with incontinence needs have their personal supplies stored in their rooms and had sufficient supply of wipes, diapers, pull ups, and changing pads. LPA interviewed W1 and witness stated that they visit with C1 at least 4 times a year and in each visit client has not mentioned these issues nor have they observed C1 to be dirty or displaying an odor that would corroborate with the above allegation.

Based on statements and interviews conducted with staff/clients/witness, review of client files and hygiene supplies, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report will be emailed to Edith Silva, earsilva95@gmail.com

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC9099 (FAS) - (06/04)

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