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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005617
Report Date: 09/22/2023
Date Signed: 09/22/2023 03:18:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/22/2023 03:18 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 ASC, 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:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Edith Silva - AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit to Xavier Home 2 for the purpose of conducting an annual inspection. LPA arrived to the facility at 2:45pm and was greeted by Administrator (AD) Edith Silva.

The facility is undergoing full renovations and construction. Residents are currently residing at 14775 Firestone Blvd. La Mirada, CA. LPA observed no clients to be present at the facility on Dogwood Ave.

Per Licensing Information System (LIS) LPA determined that the annual fees are not current. LPA made Licensee aware of unpaid annual fees. LPA provided Licensee with amount of fees owed, PIN, CDSS website to pay. LPA suggested paying online. LPA stated the payment is due 30 days from the visit. A citation is being issued. LPA provided Licensee with step-by-step instructions how to pay.

Based on the observations and LIS review, one deficiency is being cited as per Title 22 Division
6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administrator Edith Silva, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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Document Has Been Signed on 09/22/2023 03:18 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 09/22/2023 at 02:56 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: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2023
Section Cited
CCR
80036(a)

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(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. Based on record review, the licensee did not comply with the above citation due to 2023 annual fees not being paid. This presents a potential risk to clients as the facility must pay annual
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Licensee will ensure the 2023 annual fee and late fee are paid by 10/23/2023 the assigned POC due date. Licensee will submit proof of payment to LPA via email by 10/23/2023 the assigned POC due date.
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fees in order to continue to operate and administer care to their clients.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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