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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005617
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:20:35 PM

Document Has Been Signed on 08/30/2022 02:20 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: 0DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Edith SilvaTIME COMPLETED:
02:23 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 the required annual inspection (mitigation). LPA met with Administrator Edith Silva. LPA explained the reason for the visit. The facility is currently empty and no one lives at the facility. Clients have been relocated (see LIC 809 dated 7/19/2022). LPA verified the facility is empty. Facility is under going renovations. Administrator reported there is no definite time frame of when the facility renovations will be completed due to supply shortages and waiting for city inspections. No deficiencies are being cited as a result of this visit. LPA informed the Administrator that a visit to the client's location can happen without notice, Administrator stated she understood. 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: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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