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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601349
Report Date: 12/22/2025
Date Signed: 12/22/2025 08:47:28 PM

Document Has Been Signed on 12/22/2025 08:47 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:
12/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Care giver-Demar MondragonTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elena Mallett arrived at the facility to conduct and unannounced Annual visit. LPA Mallett met with Direct Support Providers Demar Mondragon and Analiza Mondragon and explained the purpose of the visit. Administrator Edith Silva spoke with LPA Mallett on phone and said that Direct Support Providers can lead the tour and sign for the Licensing Report.

The facility is licensed to serve 4 disabled, non- ambulatory only adults ages 18-59. There is currently 4 clients residing at the facility. The facility is located in a residential neighborhood in Norwalk.The facility consists of 4 client bedrooms, a living room, kitchen, dining room, activity room, 3 bathrooms , a garage, front and back yard patios.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains a 1000 dollar Surety Bond.

Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. Required furnishings and proper lighting was observed in all the client rooms. Hallways were clear and free of obstruction.

809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2025
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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Document Has Been Signed on 12/23/2025 04:10 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/23/2025 08:55 AM


Created By: Elena Mallett On 12/22/2025 at 04:44 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
MONTEREY PARK ASC, 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: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that 1 out of 4 staff, Staff 4(S4) did not have a criminal background clearence on file. This poses an immediate health and safety risk to clients in care.
POC Due Date: 12/23/2025
Plan of Correction
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4
Licensee will obtain Criminal Background Clearance for S4 and associate S4 to facility in Guardian by POC due date. POC cleared during visit.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 12/22/2025 08:47 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/22/2025 at 04:44 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: 12/22/2025

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, 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.
POC Due Date: 01/06/2026
Plan of Correction
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By POC due date Licensee will submit photos of repaired broken items to LPA via email.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the outdoor patio seating bench and chair were not in good repair to provide seating for enjoying the outdoors.
POC Due Date: 01/06/2026
Plan of Correction
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 By POC due date Licensee will send photo of patio furniture that is in good repair for client use to LPA via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 08:47 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/22/2025 at 04:44 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: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(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.

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 3 out of 4 clients ( C2-C3) did not have a recent needs and services plan in their file.
POC Due Date: 01/06/2026
Plan of Correction
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By POC due date Licensee will submit via Licensing FAX, updated Needs and Services Plans for C2, C3 and C4
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review , C3, did not have 2 PRN medications available at the facility for which there were doctors orders. This poses a potential safety risk to 1 out 4 clients in care.
POC Due Date: 01/06/2026
Plan of Correction
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By POC due date Licensee will provide proof of filled presciption from pharamacy via Licensing Fax.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 08:47 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/22/2025 at 04:44 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: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)(7)(G)
Other Provisions
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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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.
POC Due Date: 01/06/2026
Plan of Correction
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By POC due date Licensee will provide a copy of updated Disaster Plan to Licensing Fax.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


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: 12/22/2025
NARRATIVE
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Physical Plant continued

There were operable smoke detectors observed in each bedroom and garage. An operable carbon monoxide detector was observed along with 2 fully charged fire extinguishers. The garage is used for storage. Cleaners and toxins were stored in a locked cabinet away from any food. Emergency food, extra linens and hygiene supplies sufficient for clients in care was observed. LPA observed the following items to be in need of repair: the dryer was rusted and not operable, there was a stain on ceiling in clients' bedroom. Per DSP, possibly from water. The shower chair was observed to have a rip in it and the patio furniture in the front yard was broken and could pose a scratch risk for someone sitting on it. The gate in front was observed to loose, not adhering to the other sections of the gate.

Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Edith Silva's certificate is current 02/25/2027.

Personnel Records-Training: 4 staff files were reviewed. All staff had current CPR and FIrst Aid Training. Staff 4 was not associated on Guardian at the time of the visit. See 809-D. Civil Penalities will be issued today. Administrator did not have updated HIV and TB training. See 809-D.

Client Records-Incident Reports: Client files are kept in a locked room and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. 4 client files were reviewed. Deficiencies were found. See 809-D

Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Food was observed to be stored properly and refrigerator and appliances were operable.

Health Related Service: Staff utilizes a medication Log. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers.

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

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
Page: 8 of 8
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: 12/22/2025
NARRATIVE
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Incidental Medical & Dental: All medications for clients are kept in a locked closet and inaccessible to other clients. 2 clients medication logs were reviewed. A deficiency was found. See 809-D.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. A Disaster Plan was provided to LPA. A deficiency was noted. See 809-D

Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

The PNI accounts for Clients C1-C4 whose resources were handled by facility were reviewed with no issues. A current Surety Bond for 1000 dollars was provided.

LPA conducted 2 staff interviews and 1 client interview during today’s visit.

Direct Support Provide , Chirs Evansr arrived at the facility in the afternoon to fill in for departed DSP. Administrator Silva authorized Chris Evans to sign for the report and complete the visit with LPA.

Administrator Silva obtained clearance in Guardian for associated staff at the end of the visit today.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Civil Penalty in the amount of $500 was issued. An exit interview was conducted with Direct Support Person Chris Evans and a copy of this Licensing Report and Appeal Rights was provided.

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

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
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