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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005988
Report Date: 04/22/2025
Date Signed: 04/22/2025 11:31:54 AM

Document Has Been Signed on 04/22/2025 11:31 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 RO, 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:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Martin Lopez AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Martin Lopez and explained the reason for the visit. The facility currently has five clients of which four are at day program.

The facility is a two story home with three client bedrooms, two bathrooms, kitchen, dining room, living room, backyard, staff office and attached two car garage. The facility appears clean, safe, and sanitary. The staff office is locked making it inaccessible to clients in care. The kitchen appears clean and sanitary. LPA observed the facility has a two day perishable and seven day non-perishable food supply on hand. LPA observed the sharps to be locked in a drawer located in the kitchen making them inaccessible to clients in care. LPA observed toxins locked under the kitchen sink making them inaccessible to clients in care. LPA observed the medication to be stored and locked in a closet located by the kitchen making them inaccessible to clients in care. LPA observed that all client bedrooms had the required components and furnishings. LPA observed that the bathrooms had toilet paper, paper towels, and textured shower floors. LPA tested the water to be 109.7 degrees Fahrenheit in the bathroom located by the kitchen and 111.2 Degrees Fahrenheit in the bathroom located in the hallway. LPA observed extra clean linens located in the hall closet for client use. LPA observed two fire extinguishers both charged with a service date of March 10, 2025. LPA tested the fire and carbon monoxide detectors and they were found to be operational. LPA observed the emergency food and water supply located in the garage and in the closet in the hallway. The facility has an alarm on the front door that is connected to client bracelets for notification of leaving the house.

Continue on 809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/22/2025 11:31 AM - It Cannot Be Edited


Created By: Hanna Gough On 04/22/2025 at 11:06 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: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 signed admission agreements which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Administrator stated that they will email signed admission agreements to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ARCHER I HOUSE
FACILITY NUMBER: 306005988
VISIT DATE: 04/22/2025
NARRATIVE
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LPA reviewed P&I with facility staff and no discrepancies were observed. LPA reviewed client medication and no discrepancies were observed. LPA reviewed client files and three out of five did not have signed admission agreements. LPA reviewed staff files and no discrepancies were observed. All staff present are background cleared and associated to the facility. The last fire drill was conducted on April 7, 2025.

Based on today’s observations citations were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Martin Lopez and a copy of this report along with LIC 858, LIC 859, LIC 809-D and appeal rights were given at the time of inspection.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
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