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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426354
Report Date: 03/20/2025
Date Signed: 03/20/2025 11:04:09 AM

Document Has Been Signed on 03/20/2025 11:04 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:XAVIER FAMILY HOMEFACILITY NUMBER:
366426354
ADMINISTRATOR/
DIRECTOR:		CARDEN, LORIFACILITY TYPE:
735
ADDRESS:9255 PALM LANETELEPHONE:
(909) 574-8129
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 4DATE:
03/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lori CardenTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to the facility for the investigation of complaint number: 56-AS-20250307162903. LPA met with Lori Carden who was advised of the purpose of today's visit.

During today's visit, LPA delivered findings for complaint number: 56-AS-20250307162903. LPA explained to Lori that although, there was not enough evidence to support the allegation of "Staffs are physically abusing clients in care" LPA was provided audio that supports Staff #1 expressing verbal aggression towards client #1. Which poses an immediate Health, Safety, or Personal Rights risk to clients in care. LPA explained to Lori that one (1) deficiency will be issued. Refer to LIC 809D for deficiency cited.

An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Facility Administrator Lori Carden.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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Document Has Been Signed on 03/20/2025 11:04 AM - It Cannot Be Edited


Created By: Paola Guerrero On 03/20/2025 at 10:42 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: XAVIER FAMILY HOME
FACILITY NUMBER: 366426354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
HSC
80072(3)

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Personal Rights 80072.... (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of punitive nature, including but not limited to: interference with the daily living function, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning.

This requirement is not met as evidence by:
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Based on interviews, and record review, the licensee did not follow personal rights regulation for 1 out of three clients The Licensee has agreed to read over the "Personal Rights 80072(3)" regulation and will provide training to all staff pertaining to the regulation. Licensee will email LPA a copy of the training that will be acknowledged and signed by all staff by POC date 3/21/2025.
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Based on interviews, and record review, the licensee did not follow personal rights regulation for 1 out of three clients in care, which poses an immediate Health, Safety, or Personal Rights risk to clients in care.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Paola Guerrero
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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