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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005617
Report Date: 07/19/2022
Date Signed: 07/19/2022 04:35:20 PM

Document Has Been Signed on 07/19/2022 04:35 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:
07/19/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Edith SilvaTIME COMPLETED:
04:52 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced Collateral visit for the facility at 14775 Firestone Blvd, La Mirada. LPA met with Licensee/Administrator Edith Silva. LPA explained the reason for the visit. At the time of the visit all clients were with caregivers at a local veterinarian's office because one of the client's pets was in need of medical care.

It was reported to the Department by the Licensee/Administrator that the 3 clients from Xavier Home 2 were relocated to another licensed facility (owned/operated by the Licensee) in Norwalk CA. Licensee reported that the facility the clients had been relocated to, was empty and the Regional Center of Orange County along with the responsible parties for the clients had been notified and approved the relocation. Licensee reported that she had begun renovations on Xavier Home 2 and the facility footprint was in the process of being changed. LPA advised the Licensee to provide a new facility sketch and a list of all the clients who had been relocated.

On 7/01/2022 the Regional Center of Orange County informed the Department that the clients had been moved from the facility in Norwalk to a hotel in La Mirada. Collateral visits were conducted by LPA Joseph Alejandre on 7/1/22 and 7/3/22 to check on the welfare of the clients. No immediate health and safety concerns were noted on the visits and no citations issued.

The 3 clients are staying in 2 rooms. One room has one client and one caregiver and the other room has 2 clients and one caregiver.

The Department is concerned about the following issues that have been caused by the relocation and verified by the two collateral visits. One of the clients is non-ambulatory and utilizes a wheelchair. The room they are staying in does not have an ADA compliant bathroom. Both rooms have 2 beds, each client has their own bed, but they do not have a private room. Each hotel room is one big room with a kitchen area and a bathroom. There is no privacy in either room. The Licensee did not report any of the changes until after they had taken place. The Department was not notified about the relocation of the clients until they had already moved out of the County and there was no report of the Alterations to the facility building until after construction had begun. Continued.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: XAVIER HOME 2
FACILITY NUMBER: 306005617
VISIT DATE: 07/19/2022
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It was observed that there were only 2 caregivers (same caregivers at each visit) for the 3 clients during each visit at the hotel. It was reported by staff that they had worked continuously since the move to the hotel with only a few breaks, the longest being around 4 hours. The Department is concerned that there is a lack of care and supervision for the 3 clients that could compromise their safety.

The Department concluded that based on documentation and information available, the Licensee did not report the proposed changed as required by regulation. The facility is undergoing renovations and it is unclear on when the project will be completed and the facility will need to have a new fire clearance inspection. The clients are not in immediate danger however, the clients are experiencing an upheaval to their routine which has put them in a situation where their rights are being violated and the risk of compromised care has greatly increased.
Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 1. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided to the Licensee.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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Document Has Been Signed on 07/19/2022 04:35 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 07/19/2022 at 02:59 PM
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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited
CCR
80061(b)

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Reporting Requirements - Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below... In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Licensee states they will report all incidents as required by Title 22 regulations and provide a written statement that the regulation 80061 has been read and reviewed. Licensee agrees to comply with all reporting requirements required by Title 22. Licensee to submit proof to LPA by POC due date.
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This requirement is not being met as evidenced by; A record review of incident reports (SIRs) submitted to the Agency revealed the Licensee did not submit a written incident report within 7 days of the clients relocating. This poses an immediate Health and Safety risk to clients in care.
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Type A
07/20/2022
Section Cited
CCR80086(a)

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Alterations to Existing Building or New Facilities - Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not being met as evidenced by;
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Licensee states they will provide a detailed plan of all proposed changes including a detailed facility sketch showing all of the new changes. Licensee states they will complete a new application and request a new fire clearance inspection at the time of completion. Licensee agrees to keep the Agency informed of all progress.
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Licensee verified that the facility was being altered and under renovations prior to notifying the Agency on 6/28/22. This poses an immediate Health and Safety Risk to clients in care.
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Licensee to provide the LPA with the detailed plan and facility sketch 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.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


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