<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005617
Report Date: 07/01/2022
Date Signed: 07/01/2022 05:12:51 PM

Document Has Been Signed on 07/01/2022 05:12 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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:
07/01/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Christopher EvansTIME COMPLETED:
05:16 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a Collateral visit at 14775 Firestone Blvd, La Mirada. The Agency (CCL) received a report that 3 clients of Xavier Home 2 have been relocated. The 3 clients have been relocated at this location while the facility is under going renovations. The location is a hotel. LPA was greeted and granted entry by staff. LPA met with staff and explained the reason for the visit. LPA observed Client 1 (C1) who was taking a nap in the room. LPA observed there is food and snacks in the room, cereal and instant oatmeal. LPA observed C1 has their belongings in 3 suitcases and a backpack. LPA observed medications are kept secured in storage box. Staff reported C1 has communicated with their family and is still attending their day program. LPA met with Client 2 (C2) and Client 3 (C3) and Staff 1 (S1) who are located in a different room. LPA interviewed C2, C3 and S1. LPA observed the clients had clothes and toiletries with them. There was some dried food such as chips and cereals and oatmeal. LPA observed a case a bottled water in the refrigerator. Staff and clients reported they had lunch at a fast food restaurant. Both rooms had a 2 burner electric stove, a small microwave oven and a refrigerator and a small sink. The room is one great room with a half wall separating it in two, to function as two bedrooms but neither half is private. One bed is a pull out couch and one bed is a queen size bed. Both rooms are identical. Each bed has a night stand and a lamp. There is a TV in front of each bed. There is a chair in the corner of each room next to the couch with the pull out bed. There is a small table by the kitchen area. Each room has one bathroom which is not ADA compliant. The rooms are clean. The hotel is clean. Both rooms have air conditioning and the temperature was 72 degrees Fahrenheit. Each resident has their own bed but 2 of the residents sleep on the pull out beds. The medication in the second room visited was in a kitchen cabinet that is not secured. LPA thanked the staff and clients for their time. No obstacles or hazards observed. No immediate health or safety concerns noted. No deficiencies are being cited at this time. An exit interview was conducted and a copy of this report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1