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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005453
Report Date: 04/19/2023
Date Signed: 04/19/2023 01:32:37 PM


Document Has Been Signed on 04/19/2023 01:32 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:SILVER LINING RESIDENTIAL CAREFACILITY NUMBER:
306005453
ADMINISTRATOR:FADDOUL, LACYFACILITY TYPE:
740
ADDRESS:1243 N. BROOKHURST STREETTELEPHONE:
(661) 810-7293
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:14CENSUS: 10DATE:
04/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Miriam Esquivel, Lacy FaddoulTIME COMPLETED:
01:45 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Miriam Esquivel and discussed the purpose of the inspection. Administrator (AD) Lacy Faddoul arrived during the inspection.
At about 8:40AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure. This is a two-story home. Facility is a 9-bedroom, 4-bathroom, two-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the residents. LPA observed there were 4 staff and 10 residents present. Resident Bedrooms. The 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. The 3 staff bedrooms are spacious and will easily accommodate the staff’s furnishings. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 106.5 and 109.5 F degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen cabinet. Toxins: observed locked in the closet and in the garage. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. At about 11:45AM, LPA reviewed 5 resident files and 5 staff files. Facility does not handle resident money. At about 12:10PM, LPA inspected the medications for 5 residents. At about 12:20PM, LPA interviewed 3 staff and 5 clients. LPA requested and obtained copies of the resident roster, staff roster, proof of insurance, administrator certificate, and resident files. At about 11:15AM, LPA and AD observed the following: Staff #2 (S2) is not background cleared. During the inspection, AD had S2 removed from the facility and LPA confirmed. AD stated that S2 will not be allowed back to the facility until they are background cleared.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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 3


Document Has Been Signed on 04/19/2023 01:32 PM - It Cannot Be Edited

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: SILVER LINING RESIDENTIAL CARE
FACILITY NUMBER: 306005453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and documents, 1 out of 5 staff checked is not background cleared, which poses an immediate health and safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 04/20/2023
Plan of Correction
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During the inspection, AD had S2 removed from the facility and LPA confirmed. AD stated that S2 will not be allowed back to the facility until they are background cleared. POC Cleared.
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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: SILVER LINING RESIDENTIAL CARE
FACILITY NUMBER: 306005453
VISIT DATE: 04/19/2023
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Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC809 (FAS) - (06/04)
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