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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005988
Report Date: 04/30/2024
Date Signed: 04/30/2024 11:57:46 AM

Document Has Been Signed on 04/30/2024 11:57 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ARCHER I HOUSEFACILITY NUMBER:
306005988
ADMINISTRATOR/
DIRECTOR:		LOPEZ, ANICIAFACILITY TYPE:
735
ADDRESS:520 S ARCHER STTELEPHONE:
(714) 776-8536
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Martin Lopez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Faith La arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted and granted entry into facility by Teresita Ringor Direct Care Staff, Cresta Narcise, Caregiver. QA Manager Early Maglaya joined the inspection approximately 10 minutes after LPAs' arrival. Facility Administrator Martin Lopez and House Manager Maltide Ventura joined for part of the inspection.

The facility is a one-story home with three client bedrooms, two bathrooms, kitchen, dining room, living room, backyard and attached 2-car garage. LPAs noted four out of five clients were away at day program. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 105.4 and 107.7 degrees Fahrenheit in the bathrooms. LPAs observed facility has emergency food and water supply. LPAs noted Fire Extinguishers were last serviced on 3/22/2024. LPAs observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen and cabinets in the garage. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a closet near the kitchen. The backyard has a shaded sitting/lounging area. Exit gate is unlocked. LPAs observed exit gates to be unobstructed. LPAs reviewed three of the five client files and four staff files. LPAs also reviewed medication for three out of five clients. Facility staff notified LPAs that P & I funds are not kept on the premises. They are kept with the Assistant House Manager. LPAs notified facility staff that P& I funds must be accessible to clients when they want to access it. A deficiency is being issued. LPA noted windows in client rooms to be in disrepair, unused items in backyard, a broken latch on one of the side gates and broken doors on an outdoor storage shed. A deficiency is being issued.

Two deficiencies are being issued based on today's inspection. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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 04/30/2024 11:57 AM - It Cannot Be Edited


Created By: Dwayne L Mason On 04/30/2024 at 11:24 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARCHER I HOUSE
FACILITY NUMBER: 306005988

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to windows in all client rooms being in disrepair, a broken gutter and unused bed frame in the backyard, a broken latch on one of the side gates and broken doors on the outdoor storage shed. This poses a potential safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Facility Staff stated they will repair the windows, remove the broken gutter and unused table from the property, repair the latch on the side gate and repair the door on the outdoor storage shed by the assigned POC due date of 5/14/2024. LPA will verify completion at a POC inspection.
Type B
Section Cited
CCR
85072(b)(7)
(b) The licensee shall insure that each client is accorded the following personal rights. (7) To possess and control his/her own cash resources.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above due to the fact that the facility keeps the P&I cash with the Assitant House Manager who was not available to come to the facility at the time of inspection. This poses a potential personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Facility Staff stated they will store P&I cash in the facility and ensure that at least one on-site staff member has access to it at all times to ensure clients can access their funds when they would like. LPA will verify this correction at a POC inspection.
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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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