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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005617
Report Date:
08/11/2022
Date Signed:
08/30/2022 02:51:40 PM
Document Has Been Signed on
08/30/2022 02:51 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 2
FACILITY NUMBER:
306005617
ADMINISTRATOR:
REYNOSO SILVA,EDITH
FACILITY TYPE:
735
ADDRESS:
1401 DOGWOOD AVE
TELEPHONE:
(714) 991-7122
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
5
CENSUS:
0
DATE:
08/11/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:15 AM
MET WITH:
n/a
TIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Joseph attempted a visit at the facility. The facility was empty and is under going renovations. LPA did not observe anyone at the facility. Facility was secured and there is no evidence of anyone residing at the facility. LPA will contact the Licensee/Administrator for more information.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/11/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2022
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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