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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601349
Report Date: 06/29/2022
Date Signed: 06/29/2022 04:21:24 PM

Document Has Been Signed on 06/29/2022 04:21 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:
06/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Edith SilvaTIME COMPLETED:
04:30 PM
NARRATIVE
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On 6/29/22 at 2:00 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management inspection at the facility. LPA met with Administrator Edith Silva and discussed the purpose of the visit, which is to gather additional information regarding the facility operating over capacity.

According to the information received prior to case management visit. Administrator has moved another client into the facility due to renovation at another home in Orange county. With the addition of C1 the facility will have a total of 5 clients. The client 1 (C1) is under Orange county regional center.

During today's visit, LPA toured the facility with administrator. LPA interviewed Administrator and Client 3. LPA obtained a photo of staff roster and written client roster.

During the tour LPA observed 4 clients and administrator and staff confirmed another client is currently at a day program. Administrator confirmed other home will be renovated for 2 months. Administrator stated C1 has lived at the facility between 1- 1 ½ weeks and belongs to Orange County Regional center. Administrator also stated C1 is at the facility because C1 wants to sleep with family member C2, but C1 has a room at administrators home not to far from the facility. C3 stated the C1 is not part of the facility but sleeps with C2. Administrator stated C1 will not sleep here as of 6/29/22 but will visit C2 during the day.
Report continued on 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198601349
VISIT DATE: 06/29/2022
NARRATIVE
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Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D and civil penalties assesed): Exit Interview Conducted with administrator / Appeal Rights Provided / A Copy of the Report Issued To administrator Edith Silva.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2022 04:21 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 06/29/2022 at 03:51 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: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2022
Section Cited
CCR
80020(a)

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Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal

The requirement was not met as evidence by:
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Administrator will ensure facility is operated with in fire clearance regulation. Administrator stated C1 will move out of the facilty today 6/29/2022. Licensee shall submit a written plan outlining how to ensure compliance with regulation section cited and submit to LPA Baptiste by POC due date of 6/30/22.


*** An immediate Civil Penalty is being issued today for $500 for failure to obtain an approved fire clearance before the admission of residents to the facility. ****
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Administrator confirmed C1 was sleeping at the facilty with family member C2 due to renovation of facility in Orange county. Administrator fire clearance is approved for 4 clients. C1 will become the 5 client at the facility, which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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