306005617-8-28-2025-22-AS-SHAN-DKYPZE-20250828114525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005617
Report Date: 08/28/2025
Date Signed: 08/28/2025 11:46:29 AM

Document Has Been Signed on 08/28/2025 11:46 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: 3	DATE:	08/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Chris Evens		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility for the purpose of completing the required Annual Inspection. Upon arrival, LPA was greeted and granted entry by caregiver, Christophor Evens.

The facility is a two-story residence. The second floor contains three bedrooms and two restrooms for staff use, while the first floor contains three bedrooms and two restrooms designated for clients in care. Common areas include a kitchen, dining room, and living room.

During the inspection, LPA observed smoke detectors and carbon monoxide detectors in all required areas, including client bedrooms and common spaces. All detectors were tested and found to be operational. Client bedrooms were equipped with required furnishings, including appropriate bedding, linens, and closet/drawer space. Client bathrooms were inspected and found to have properly functioning toilets and faucets, secure grab bars, and showers free from mold or mildew. Water temperatures were measured at 118 degrees Fahrenheit in the first restroom and 116.8 degrees Fahrenheit in the second restroom, both within regulatory range. Towels and personal hygiene supplies were adequately stocked. The facility was observed to be clean, free of hazards, and with unobstructed doorways. The first aid kit contained all required items, including bandages, thermometer, tweezers, scissors, and a first aid manual. Kitchen appliances were in working order. LPA observed sufficient food supplies, consisting of a two-day supply of perishable items and a seven-day supply of non-perishables. {***CONTINUE}***

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 08/28/2025

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However, sharps and knives were observed stored on top of the refrigerator in the kitchen, making them accessible to clients in care. In addition, chemicals and disinfectants were observed in the laundry room, which was unlocked and accessible to clients. These conditions pose immediate safety risks. A review of two client files and two staff files showed that all required documentation was maintained. The fire extinguisher was fully charged and had last been inspected on July 11, 2025. The most recent fire drill was conducted on August 4, 2025. A tour of the backyard revealed that the main fire exit door was locked and required a key to open. This condition could present an obstacle during an emergency evacuation and poses immediate safety risks.

Based on today’s visit, deficiencies are being cited in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to staff at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2025 11:46 AM - It Cannot Be Edited

Created By: Samer Haddadin On 08/28/2025 at 11:29 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: XAVIER HOME 2	FACILITY NUMBER: 306005617
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in havining a lock on the emergency exit door which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2025
	Plan of Correction
1 2 3 4	Licensee to remove lock and send proof to LPA via E mail by POC due date

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in disinfectants and cleaning solution in the laundry room and accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2025
	Plan of Correction
1 2 3 4	Licensee to lock laundry room and send proof to LPA via E mail by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025

LIC809 (FAS) - (06/04)

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