306006540-9-30-2025-22-AS-AORZ-DMAS9W-20251009134122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006540
Report Date: 09/30/2025
Date Signed: 09/30/2025 11:27:45 AM

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
07/11/2025 and conducted by Evaluator Hanna Gough

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250711143419

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: 3	DATE:	09/30/2025
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Miriam Esquivel		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff did not seek appropriate medical treatment for resident, resulting in resident death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with House Manager (HM) Miriam Esquivel and discussed the purpose of the visit.

The investigation into the allegation of Facility staff did not seek appropriate medical treatment for resident, resulting in resident death revealed the following: On June 14, 2025, around 1PM Resident #1 (R1) was picked up from the facility by their Responsible Party and was admitted to the hospital on June 15, 2025, with a diagnosis of pneumonia. R1 was admitted to the facility on May 4, 2019. LPA observed a Physicians Report for R1 dated May 28, 2024, stating that R1 has Down Syndrome, cannot manage their own medications and are able to communicate their needs. R1 had a Resident Appraisal dated June 4, 2019, signed by R1’s responsible party, that stated that they had a chronic cough. LPA observed an Individualized Program Plan (IPP) for R1 dated November 1, 2024, where the facility Administrator and R1s responsible party were both present. Continue on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 22-AS-20250711143419

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: 09/30/2025

NARRATIVE

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The IPP stated that R1 has a chronic cough and that they had cough medication prescribed as needed. LPA observed progress notes by R1’s physician dated May 28, 2025, stating that R1’s chest was clear, reviewed R1’s medication list and to continue the present plan of care for R1. Per R1’s medication list for the month of June 2025, R1 was prescribed FT Tussin DM by a physician to be given to R1 by mouth every six hours as needed. Per facility’s Medication Administration Records, R1 was given a dose of medication on the morning of June 14, 2025. The facility flow sheet for R1 that stated on June 14, 2025, R1 presented with a cough and congestion, no fever and their primary physician was notified.

Per facility visitor log, R1’s responsible party signed the log at 12:40 pm on June 14, 2025, and took R1 for an overnight home visit. On June 15, 2025, the facility staff contacted R1’s responsible party and was informed that R1 was admitted to the hospital for pneumonia. The Department received an incident report on June 16, 2025, stating that on June 14, 2025, R1 presented with signs of cough and congestion with R1’s primary physician and responsible party notified. LPA obtained a text message screenshot sent on June 14, 2025, at 8:04 AM by facility staff to R1’s physician informing them of R1’s cough. R1’s primary physician did not respond with additional instructions for the facility staff.

During interviews it was revealed that two of three staff informed LPA that R1’s responsible party was informed verbally upon pick up of R1’s cough and congestion and that R1’s responsible party took them home every weekend. Three of three staff informed LPA that R1 did not have a fever on June 14, 2025, and did not present with a cough or congestion earlier in the week until June 14, 2025. One of three staff informed LPA that they gave R1’s responsible party all medications including the cough medication and informed R1’s responsible party that R1 was given a dose earlier that morning.

During interviews with R1’s responsible party it was revealed that they picked R1 up from the facility around 1pm and stated that R1 looked sick. R1’s responsible party informed LPA that they did not question staff about R1’s condition and denied staff informed them of R1’s cough. R1’s responsible party informed LPA that they took R1 home gave them aspirin and put them to bed. R1 woke up had dinner and seemed to be doing better. R1’s responsible party informed LPA that they took their temperature in the evening after dinner and R1 presented a fever so they gave R1 more aspirin and put them back to bed. Per R1’s responsible party, R1 had become incontinent during the night. R1’s responsible party assisted R1 in cleaning up and shortly after R1 sustained an unwitnessed fall. At that point, the decision was made by R1's responsible party to transport them to the hospital.

Continue on 9099-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250711143419

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: 09/30/2025

NARRATIVE

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The Department reviewed medical records from Los Alamitos Hospital for R1 from June 15, 2025, through June 19, 2025. The medical records state that R1 has a history of down syndrome, thyroid disease, obesity, elevated triglycerides, chronic cough, and acid reflux. R1 was admitted to the hospital on June 15, 2025, with a diagnosis of pneumonia and had a rapid decline while admitted. R1 passed away in the hospital on June 19, 2025, with the cause of death being listed as acute respiratory failure, viral pneumonia and down syndrome.

Based on interviews, record review and information gathered during the investigation the preponderance of evidence standard has not been met, therefore the above allegation is deemed UNSUBSTANTIATED. Meaning although the above allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred.

An exit interview was conducted with (HM) Miriam Esquivel and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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