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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005988
Report Date: 04/05/2023
Date Signed: 04/05/2023 10:36:45 AM

Document Has Been Signed on 04/05/2023 10:36 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ARCHER I HOUSEFACILITY NUMBER:
306005988
ADMINISTRATOR:LOPEZ, ANICIAFACILITY TYPE:
735
ADDRESS:520 S ARCHER STTELEPHONE:
(714) 776-8536
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
04/05/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Ramon LopezTIME COMPLETED:
10:50 AM
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Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPAs met with Applicant (AP) Ramon Lopez, discussed the purpose of the inspection, and toured the facility. Facility is to operate an Adult Residential Facility. Application was submitted to Community Care Licensing on 03/23/2021. This is a change of facility type with persons in care.

During the inspection, LPAs and AP observed the following: Structure. This is a two-story home. Facility is a 3-bedroom, 3-bathroom, home with attached garage that is being used for storage. There is a back yard with a patio cover for the clients. Facility telephone number is (714) 776-8536. client Bedrooms. The 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105.9 to 107.4 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the smoke detectors and carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen cabinet. Toxins: observed locked in the garage. Medication closet is locked. First-Aid Kit & Activity Supplies: observed and available. Client & Staff Files. LPAs reviewed 2 staff files and 3 client files. Fire clearance was approved by Anaheim Fire Department Inspector Alicia Badosa on 08/05/2021. Backyard. Backyard exit gate is operational and unlocked. Back yard has shaded area for outdoor activities and sufficient seating for clients. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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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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: ARCHER I HOUSE
FACILITY NUMBER: 306005988
VISIT DATE: 04/05/2023
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During the inspection, LPAs explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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