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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006540
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:54:34 PM

Document Has Been Signed on 12/05/2024 02:54 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ARCHER RESIDENTIAL CAREFACILITY NUMBER:
306006540
ADMINISTRATOR/
DIRECTOR:		FADDOUL, LACYFACILITY TYPE:
740
ADDRESS:421 S ARCHER STTELEPHONE:
(661) 810-7293
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
12/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:41 AM
MET WITH:Miriam Esquivel, ManagerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in our Regional Office on December 4, 2024. LPA was greeted and granted entry by caregiver. At the time of entry a grocery drop-off was also observed at the front door.

LPA spoke with Licensee (LE) Lacy Faddoul regarding associating the staff to this location. Currently only the Licensee is associated. Residents and staff were moved from the property next door, Silver Lining Manor, in October 2024. LPA confirmed with Regional Office that three of three staff members and one live-in, non-staff member, have all been fingerprinted and cleared while living at the facility Silver Lining Manor. Licensee staff background clearances will be transferred to this location.

Based on the observations and conversations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited or civil penalties assessed on this date. An exit interview was conducted with Miriam Esquivel, Manager and a copy of the report was given at the time of visit,

***** THIS IS AN AMENDED REPORT *****
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 is an Amendment of Original Document on 12/05/2024 02:28 PM


Created By: RoseMarie Ruppert On 12/05/2024 at 10:50 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARCHER RESIDENTIAL CARE
FACILITY NUMBER: 306006540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87735(c)

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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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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