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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601349
Report Date: 01/12/2026
Date Signed: 01/12/2026 09:57:11 AM

Document Has Been Signed on 01/12/2026 09:57 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
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: 3DATE:
01/12/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:57 AM
MET WITH:Administrator Edith SilvaTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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 Licensing Program Analyst (LPA) Elena Mallett made an unannounced POC visit to facility to clear citations from 12/22/25 Annual visit.LPA Mallett was met by Administrator Edith Silva and the purpose of the visit was discussed.LPA Mallett toured the facility and reviewed records and the following was observed.

CCR 80087(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.

On 12/22/25 -Based on observation, the licensee did not comply with section above as the dryer was inoperable, the shower chair was torn, the front patio bench and front gate were broken and ceiling in client's bedroom was stained. This poses a potential health and safety risk to 4 out 4 clients in care.

By POC due date Licensee will submit photos of repaired broken items to LPA via email.

At 01/12/26 visit LPA observed : Prior to visit on 01/06/26 LPA had been provided with pictures showing broken bench had been removed, stain on ceiling had been painted and a repairman for the Gate had been contacted via email. During today’s visit it was observed a new dryer had been purchased. Administrator Silva provided proof of correspondence with insurance entity about Shower Chair repair. Administrator provided proof of correspondence with fence contractor. LPA will clear citation when photo of work completed is submitted. No civil penalty was issued today.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 01/12/2026
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CCR 85087.2(b) (b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

Based on observation the outdoor patio seating bench and chair were not in good repair to provide seating for enjoying the outdoors.

By POC due date Licensee will send photo of patio furniture that is in good repair for client use to LPA via email.

At 01/12/26 visit LPA observed patio furniture in good repair, in sufficient number for clients in care to be present in shady outdoor area. Clients have area to enjoy the outdoors. Citation cleared.

CCR 85068.2(a)- The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

Based on record review, the licensee did not comply with the section cited above 3 out of 4 clients ( C2-C4) did not have a recent needs and services plan in their file.

By POC due date Licensee will submit via Licensing FAX, updated Needs and Services Plans for C2, C3 and C4

At 01/12/26 visit LPA observed Administrator Silva provided proof of September 2025 IPP meetings for all clients in which needs and services were discussed. Administrator will print out for file upon receipt from Regional Center Service Coordinator Ceasar Escobar. Citation cleared.

HSC 1565 (a) (7)(G)- (a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to the following: (G) A process for identifying individuals served by the facility who have special needs, and a plan for meeting those needs.

Based on record review the Disaster Plan did not provide sufficient detail of how to the needs of clients who use wheelchairs and a Gtube will be met during a disaster. This affects 3 out of 4 clients in care. This poses a potential health and safety risk to clients in care

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
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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: 01/12/2026
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By POC due date Licensee will provide a copy of updated Disaster Plan to Licensing Fax.

During 01/12/26 visit LPA and Administrator Silva discussed at length facility's disaster plan and how it would address the needs of the clients with wheel chairs and Gtube in the event of a disaster. Administrator sent updated plan to Office Fax. Citation cleared.

No civil penalties were issued today. An exit interview was conducted with Administrator Silva and a copy of this Licensing report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
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