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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005617
Report Date: 03/26/2024
Date Signed: 03/26/2024 11:03:43 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240216162846
FACILITY NAME:XAVIER HOME 2FACILITY NUMBER:
306005617
ADMINISTRATOR:REYNOSO SILVA,EDITHFACILITY TYPE:
735
ADDRESS:1401 DOGWOOD AVETELEPHONE:
(714) 991-7122
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:5CENSUS: 3DATE:
03/26/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Edith Silva- AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff inappropriately played with client causing client to feel uncomfortable.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit to the Extended Stay America Hotel for the purpose of delivering the amended findings into the above allegation. Clients are residing at the hotel as the facility is undergoing renovations. LPA visited one unit and met with Care Staff (CS) Chrisotpher Evans and explained the reason for the unannounced visit. LPA observed two clients in the room. LPA explained the reason for the visit to Administrator Edith Silva by telephone at 9:16am who then arrived to the hotel at 9:43am.

On February 23, 2024, LPA initiated the complaint investigation at the hotel from 3:48pm to 6:00pm. During the initial visit, LPA interviewed two clients and three staff. Pertinent documentations were received via email on February 26, 2024, at 10:09am, which includes the client/staff roster, three out of three clients face sheets, medical records, Individual Program Plans (IPPs), and the quarterly reports. Additional interviews were conducted by telephone which the investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20240216162846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: XAVIER HOME 2
FACILITY NUMBER: 306005617
VISIT DATE: 03/26/2024
NARRATIVE
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It is alleged that the staff inappropriately played with the client causing the client to feel uncomfortable. Based on the review of the IPP of Client #1 (C1), C1 does not have a history of making false accusations.
Although interviews revealed that two out of the three clients indicated feeling safe and comfortable around Staff #1 (S1), three out out of the three staff acknowledged that the prank to scare C1 transpired. It is determined based on the evidence obtained and the admission made by three out of three staff, the prank is in fact considered an inappropriate play.

Therefore, based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff inappropriately played with client causing client to feel uncomfortable is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 1 of the California Code of Regulations. A deficiency is being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Edith Silva, and a copy of this report including the LIC9099C, LIC9099D, and the appeal rights were provided during today's visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240216162846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: XAVIER HOME 2
FACILITY NUMBER: 306005617
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2024
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) "... each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable...to meet his/her needs."
This requirement was not met as evidenced by:
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Administrator stated that they will provide proof of an in-service training for all staff and to submit an Acknowledgment of Understanding of 'the said deficiency to LPA via email by POC due date.
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Based on interviews and record review, S1 did not make the client feel comfortable by inapproriately playing (or pranking) C1 which poses a potential 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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3