306006540-5-20-2025-22-AS-AORZ-DH6PW2-20250530113957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006540
Report Date: 05/20/2025
Date Signed: 05/20/2025 02:56:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2024 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20241204151556

FACILITY NAME:	ARCHER RESIDENTIAL CARE		FACILITY NUMBER:	306006540
ADMINISTRATOR:	FADDOUL, LACY		FACILITY TYPE:	740
ADDRESS:	421 S ARCHER ST		TELEPHONE:	(661) 810-7293
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 4	DATE:	05/20/2025
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Miriam Esquivel, Administrator Designee		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Questionable death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility to deliver findings for a complaint visit conducted on December 5, 2024. A complaint was registered with the Department on December 4, 2024. LPA was greeted and granted entry and explained the purpose of the visit. LPA met with Miriam Esquivel, Administrator Designee (AD) and explained the purpose of the visit.

On December 5, 2024, LPA conducted a 10-day complaint visit to investigate the Questionable Death of Resident #1 (R1). LPA received R1’s: Identification (ID) Form, Physician's Report, Resident Appraisal, Individual Program Plan (IPP), Progress Notes, Medication Sheet for November 2024, Medical Flow Sheet and Personnel Report (LIC 500). LPA reviewed the Physician’s Report dated November 28, 2023, which lists R1’s diagnosis as cerebral palsy and mild intellectual disability. Per Resident Appraisal dated February 1, 2023, R1 does not require night observation. Facility Progress Notes showed there were no concerns noted. LPA reviewed the LIC 500 and determined there were two staff working for the five residents in care. (Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20241204151556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/20/2025

NARRATIVE

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(Continued from LIC 9099)

During the course of the investigation, the Department interviewed two of two staff members who were present at the facility on the day R1 passed away on November 26, 2024. Two of two staff reported R1 was last seen on November 25, 2024, at 8:30pm when they gave R1 medications. R1 watched television in bedroom before falling asleep. Night staff did resident rounds on November 26, 2024, at 2:30am and R1 was asleep.

LPA interviewed R1’s family member, who was surprised by R1’s unexpected passing. Family member wanted to know the cause of death and questioned if there was neglect involved. R1 has been placed at this facility since facility opened on September 1, 2024.

Per interview with AD, on November 26, 2024, at 6:55am staff went into room to wake R1 and discovered R1 was not breathing and unresponsive. Paramedics were immediately called and contacted the Coroner’s Office. Coroner’s Office released R1 to be picked up by the mortuary on file. At 9:30am Mortuary arrived to the facility for R1 to be cremated. The timeline of events was corroborated by the staff and the family member.

LPA obtained the Natural Death Summary Report from the Coroner’s Office dated November 26, 2024. The report stated resident, “…looks clean and well cared for and there are no concerns of abuse/neglect, and no history of trauma, injuries, or substance abuse.”

LPA obtained a copy of the Certified Death Certificate. The Death Certificate dated December 18, 2024, listed R1’s causes of death as: Cardiopulmonary Arrest and Atherosclerotic Heart Disease. LPA spoke with R1’s family member who felt relief that there was an official cause of death and understood R1’s health diagnoses could have contributed to R1’s unexpected death.

Although the above allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the questionable death allegation is unsubstantiated. An exit interview was conducted with Miriam Esquivel, Administrator Designee and a copy of this report was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC9099 (FAS) - (06/04)

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