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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005617
Report Date: 07/03/2022
Date Signed: 07/03/2022 01:45:26 PM

Document Has Been Signed on 07/03/2022 01:45 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:
07/03/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Salathiel "Lee" SilvaTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a Collateral visit (Health and Safety check) 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. The clients are split into two rooms. LPA visited the room on the third floor first. LPA interviewed the staff. LPA observed Client 2 (C2) was sleeping during the visit. Staff reported that Client 3 (C3) was not present. C3 went to church and then to visit family. Staff reported that C3 would contact the Administrator when she was ready to return. Staff reported that on most Sundays C3 is gone for the day visiting friends and family. LPA observed the medications were locked in the storage box and there was more dry food items stored in the room. Staff reported that the clients have enough clothing and toiletries for at least seven days. Staff reported that clients had breakfast. Staff reported there were no incidents and the clients are doing well. LPA did not observe any obstacles or hazards in the room on the third floor. Staff reported there were no plans for this day but the clients might plan on seeing fireworks on Monday the Fourth. LPA left the room on the third floor and went to the room on the second floor. LPA was greeted and granted entry by Staff. LPA observed C1 who greeted the LPA. C1 took a nap during the visit. LPA interviewed Staff. LPA observed the refrigerator was full of perishable food such as, milk, bread, lettuce, fruit, eggs, lunch meat, water, chicken, cheese and soda. LPA observed canned goods in the kitchen cabinets. Staff reported they had breakfast with Client 1 (C1). Staff reported she spoke to the Administrator today to report on the clients. Staff reported the clients and staff are doing fine. Staff reported that later today other staff would be at the location to assist. LPA observed the room on the second floor was neat and organized. LPA did not observe any obstacles or hazards in the room on the second floor. LPA did not observe any immediate health and safety concerns during the visit. LPA thanked the staff for their time. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2022
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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