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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005494
Report Date: 08/16/2021
Date Signed: 08/16/2021 02:44:54 PM

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 MANORFACILITY NUMBER:
306005494
ADMINISTRATOR:FADDOUL, LACYFACILITY TYPE:
740
ADDRESS:425 ARCHER STTELEPHONE:
(949) 682-5229
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Administrator, Iulia perezTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility and temperature was checked by Staff. LPA explained the reason for the visit.

During the visit LPA toured the facility with Administrator Iulia Perez. Facility is a Two story home with 6 bedrooms,(3 resident bedrooms 1 staff bedroom) and 2 bathrooms. LPA observed second story was vacant. There are 5 Residents in care. LPA observed proper department postings at front entrance of facility as well as a sign in, sanitization and temperature check station. LPA observed copy of Administrators Certificate expiring February 2, 2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV and playing with puzzles. Facility has audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are fully charged. Facility has supply of PPE. LPA reminded Administrator the importance of having a 30 day supply of PPE onsite at facility. Facility has 2 refrigerators and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted on wall. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. Residents emergency contact information are current. Facility has designated visitation area.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Perez and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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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