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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005617
Report Date:
08/28/2024
Date Signed:
08/28/2024 10:04:50 AM
Document Has Been Signed on
08/28/2024 10:04 AM
- 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 2
FACILITY NUMBER:
306005617
ADMINISTRATOR/
DIRECTOR:
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:
08/28/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA observed the facility is under going renovations. The front door of the facility is locked. The facility is currently empty. LPA called the Licensee/Administrator and left a message for them to contact the LPA. A copy of the this report was left in the facility mailbox.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
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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