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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005617
Report Date: 08/03/2026
Date Signed: 08/03/2026 05:13:29 PM

Document Has Been Signed on 08/03/2026 05:13 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:XAVIER HOME 2FACILITY NUMBER:
306005617
ADMINISTRATOR/
DIRECTOR:		REYNOSO SILVA,EDITHFACILITY TYPE:
735
ADDRESS:1401 DOGWOOD AVETELEPHONE:
(714) 991-7122
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 5CENSUS: 3DATE:
08/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Christopher EvansTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nancy Guillen is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA was greeted and granted entry into the facility and explained the reason for the visit. Direct Care Provider (DCP) Christopher Evans notified the Administrator. DCP notified LPA the Administrator would not be able to attend inspection. LPA observed Administrator certificate for Edith Reynoso-Silva is current with an expiration date of November 30, 2026 . This is an Adult Residential Facility licensed for five non-ambulatory clients with three clients currently residing at the facility. LPA observed three clients present at the time of visit.

LPA began the tour of the inside and outside of the facility and observed the following:

This is a two story facility with three client bedrooms, two bathrooms, a living room, kitchen, dining room, office and an attached garage with an exterior entrance. The second floor consists of four bedrooms and two bathrooms designated for staff. LPA observed required department postings posted on the wall in the office. There is a minimum of one week of non-perishables foods and two days of perishables foods available. Gas stove, microwave, and washer were all inspected and observed to be operable, however the dryer is non-operational and is scheduled for repair. The facility is maintained at a comfortable temperature. LPA observed that medication is centrally stored in a locked storage cabinet located in the laundry room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care.

Continued on LIC 809C

Kevin Saborit-Guasch
Nancy Guillen
DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2026
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 11
Document Has Been Signed on 08/03/2026 05:13 PM - It Cannot Be Edited


Created By: Nancy Guillen On 08/03/2026 at 04:31 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: XAVIER HOME 2
FACILITY NUMBER: 306005617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to cleaning solutions stored in an unlocked cabinet below the kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2026
Plan of Correction
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Licensee to send a Statement of Understanding to LPA by POC due date.
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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Nancy Guillen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2026


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: XAVIER HOME 2
FACILITY NUMBER: 306005617
VISIT DATE: 08/03/2026
NARRATIVE
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Water temperature tested between 108.3 and 111 degrees Fahrenheit. All bathrooms observed to have a supply of soap and toilet paper; however common hand towels were being used; a deficiency was cited on today's date. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants were stored in a locked cabinet in the laundry room, however some items were located under the kitchen sink in an unlocked cabinet; a deficiency was cited on today's date. The facility has an available clean supply of linens in an upstairs storage cabinet. LPA inspected clients bedrooms which have sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors and carbon monoxide detector were tested and found to be operational.

LPA toured the outside of the facility and observed outdoor passageways were free of obstructions. LPA observed there was a shaded area and seating outdoors for client use. LPA observed a fire extinguisher with service date of June 26, 2025. Fire drills are conducted quarterly with the last drill conducted on July 20, 2026. LPA began review of records. LPA reviewed three client records. All the required documentation was present and current in client files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. Receipts were attached for record keeping, however all monies were not accounted for; a deficiency was cited on today's date. LPA reviewed two employee records. LPA observed records reviewed have a current First Aid certificates.

Based on the observation made during today’s visit, deficiencies are being cited.

This report was reviewed and a copy of this report and the Appeal Rights was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
LIC809 (FAS) - (06/04)
Page: 11 of 11
Document Has Been Signed on 08/03/2026 05:13 PM - It Cannot Be Edited


Created By: Nancy Guillen On 08/03/2026 at 04:31 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: XAVIER HOME 2
FACILITY NUMBER: 306005617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (B) The use of common towels and washcloths shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to the use of common hand towels which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2026
Plan of Correction
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Hand towels were removed and paper towels were placed in the restrooms.
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in two of two client P&I's which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2026
Plan of Correction
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Licensee to update P & I records and make sure they are kept up to date. Licensee to send updated logs to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Nancy Guillen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2026


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