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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005453
Report Date: 04/10/2024
Date Signed: 04/10/2024 12:36:11 PM


Document Has Been Signed on 04/10/2024 12:36 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: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: 12DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Miriam EsquivelTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joseph Alejandre and Edward Kim made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs explained the reason for the visit. LPAs met with house manager Miriam Esquivel. LPAs and house manager toured the facility. Facility is a 9-bedroom, 4-bathroom, two-story house with an attached garage that is being used for storage. Lacy Faddoul's Administrator's Certificate expires on May 9, 2024. LPAs observed the See Something, Say Something poster (PUB 475) posted in entrance of the facility. Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher mounted next to the kitchen is fully charged. LPAs observed the kitchen is clean and organized. The stove lights unassisted. LPAs observed the knives are kept locked and inaccessible to residents. LPAs observed the medication is kept locked in a kitchen drawer. LPAs observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPAs observed all 4 bathrooms are clean and operational. Hot water measured between 108.1 and 111.3 degrees Fahrenheit. LPAs toured the resident rooms. All resident rooms had the required furnishings and linens. LPAs and the house manager toured the backyard and garage. The garage is kept locked and used for storage. LPAs observed a shaded seating area for residents to sit outside. LPAs observed the exit gate door knob was broken and non-operational. No bodies of water observed in the backyard. LPAs reviewed 4 out of 5 staff files. 4 out of 5 staff have not completed the required 20 hours of annual training. All 4 staff have completed CPR/First-Aid training. LPAs reviewed resident files. 2 out of 12 residents were missing a current reappraisal. LPAs reviewed resident medications. 1 out of 12 residents did not have all of their medications at the facility. Resident 2 was missing their Chest congestion relief DM SYR liquid which was not at the facility. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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 Has Been Signed on 04/10/2024 12:36 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
ORANGE COUNTY RO, 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(16)

To receive or reject medical care or other services.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 12 resident medications. Resident 2 did not have their chest congestion relief DM SYR medication at the facility which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Licensee agrees to have the medication shipped to the facility by the POC due date.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2024 12:36 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
ORANGE COUNTY RO, 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as the LPAs observed the door knob on the back exit gate was broken and did not operate properly which poses a potential health, and safety risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4out of 5 staff members did not have the required 20 hours of annual training which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Licensee agrees to have all staff receive the proper training as outlined in 1569.625(b)(2). Licensee to forward proof to LPA by POC due date.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/10/2024 12:36 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
ORANGE COUNTY RO, 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 12 residents, who did not have a current reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Licensee agrees to have a reappraisal completed for the 2 residents who do not have a current appraisal. LIcensee to forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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