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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005994
Report Date: 03/27/2023
Date Signed: 03/27/2023 05:26:16 PM

Document Has Been Signed on 03/27/2023 05:26 PM - 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 2 HOUSEFACILITY NUMBER:
306005994
ADMINISTRATOR:LOPEZ, ANICIAFACILITY TYPE:
735
ADDRESS:320 S ARCHER STTELEPHONE:
(714) 692-0344
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
03/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Martin J. LopezTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez and Nurse Anna Guinto made an announced visit to the facility for purpose of conducting a Pre-Licensing inspection. LPA Martinez and Nurse Guinto arrived at the facility and met with designated Administrator (AD) Martin J. Lopez. An initial application to operate an Adult Residential Facility (ARF) for a capacity of (6) non-Ambulatory was received by CCL on 03/23/2021. This is a conversion from an Intermediate Care Facility (ICF) to an Adult Residential Facility (ARF). There are currently 4 clients in care under current license.

Structure: The facility is a one story home with five bedrooms, two bathrooms, living room, kitchen, dining room, and an attached two car garage that is used for storage. There is a back yard with an exit gate on one side of the house. There is a shaded seating area in the front yard with patio table and chairs. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms: All client bedrooms have the required furnishings. LPA observed all client beds have linens and blankets. Bedrooms Staff: Facility has live-in staff. Bathrooms: Bathrooms have working plumbing and designated hand washing posters. Hot water in bathrooms is within regulatory requirements. Signal system: There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to the clients. Toxins are stored in locked garage and locked under kitchen sink cabinet. Linens & Hygiene Supplies: Supply of extra linen are stored in hallway closet. Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review were Emergency Disaster Plan with means of exiting and Emergency phone numbers listed. Menu was posted and visible. Food Service: Facility has a supply of 2-day perishable and 7-day of non-perishable food on hand for clients present. Smoke Detectors: Smoke detectors and Carbon Monoxide detectors are centrally wired and operational. Appliances: Gas stove with oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

(cont on LIC809C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 2 HOUSE
FACILITY NUMBER: 306005994
VISIT DATE: 03/27/2023
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Medications, First-Aid Kit & Book: Medication is stored in a locked cabinet in the kitchen. First Aid Kit is stored with the medication and has all the required elements. Client & Staff Files: Records are kept in hallway locked closet. Pool/Jacuzzi: Pool has a fence around it, the fence has a lock for inaccessibility. Fire Extinguisher: Fire Extinguishers are fully charged and mounted. Reading Material, Games, Activity Equipment & Materials: The facility has board games, card games, and puzzles, for clients use. Fire clearance: Was cleared on 08/05/2021. Component III: Component III was completed during today's visit.

The designated AD was notified the Pre-Licensing is complete and this facility has no deficiencies. All elements verified by LPA and Nurse Guinto appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to the email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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