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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 04:25:25 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/28/2024 04:25 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: 1DATE:
08/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:41 PM
MET WITH:Chris EvansTIME VISIT/
INSPECTION COMPLETED:
04:42 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management annual continuation visit. The facility Xavier Home 2 is under going renovations and none of the 3 clients are residing at the facility. All 3 clients are residing at 14775 Firestone Blvd La Mirada. LPA conducted the visit (collateral) at 14775 Firestone Blvd La Mirada. LPA was greeted and granted entry by staff. Only 1 client was present during the visit, LPA explained the reason for the visit. LPA interviewed staff and Client 1. LPA observed a 2 day perishable and 7 day non perishable food supply on hand in the kitchenette. No obstacles or hazards observed in the client room. Staff reported that all the files are kept with the Licensee/Administrator at her office. LPA observed client medication kept locked in a lock box. LPA called the Licensee/Administrator and informed them of the visit, the Licensee/Administrator reported they could not attend due to a prior appointment. No health and safety concerns noted during the visit. 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: 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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