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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604873
Report Date: 01/08/2025
Date Signed: 01/08/2025 09:59:01 AM

Document Has Been Signed on 01/08/2025 09:59 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:XIENNA HOMESFACILITY NUMBER:
374604873
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, DARIO FABIANFACILITY TYPE:
735
ADDRESS:10086 CASA DE ORO BLVDTELEPHONE:
(619) 718-0388
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 0DATE:
01/08/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH: Dario Gonzalez, ApplicantTIME VISIT/
INSPECTION COMPLETED:
10:09 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an announced Pre-Licensing visit. LPA was met by Applicant, Dario Gonzalez, and was granted entry into the facility. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on 08/22//2024 and the facility was approved for 4 ambulatory clients.

During today's visit, LPA, accompanied by Dario Gonzalez toured the facility inside and outside and inspected every room. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean and contained required furnishings. Toilets were found to be in working order. Facility temperature was 62 degrees F during the visit. Hot water temperature in client bathrooms measured at 114.7 degrees F. Hazardous and/or toxic chemicals were stored and secured in locked areas that are inaccessible to clients. There were locked cabinets for storage of medications. Client and staff records will be stored confidentially in the downstairs area. There was a first aid kit present in the facility. Activities and sufficient space in which to conduct activities were present. Fire extinguishers were observed in the facility. Smoke and carbon monoxide detectors were present and were recently inspected by the local fire authority. There was a pool observed on the premises that was locked and had a safety fence around it. According to the applicant, no firearms and/or ammunition were present or will be stored in the facility. Perishable and non-perishable food items were present and appropriately stored in the facility. Postings were observed in a visible area of the facility. LPA conducted Component III with the applicant. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance.

Pre-Licensing is complete, and no deficiencies were observed during the visit. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted, and a copy of this report was provided to Applicant Dario Gonzalez at the end of visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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