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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005494
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:07:29 PM


Document Has Been Signed on 06/02/2022 01:07 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 MANORFACILITY NUMBER:
306005494
ADMINISTRATOR:FADDOUL, LACYFACILITY TYPE:
740
ADDRESS:425 ARCHER STTELEPHONE:
(949) 682-5229
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Assistant Administrator, Lulia PerezTIME COMPLETED:
01:20 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 by Staff. LPA explained the reason for the visit.

During the visit LPA toured the facility with Assistant Administrator Lulia Perez. Facility is a Two story home with 6 bedrooms,(3 resident bedrooms 3 staff bedrooms) and 3 bathrooms. LPA observed second story was vacant. Second story is used for staff. There are 5 Residents in care. LPA observed proper department postings near front entrance of facility as well as a sign in, sanitization and temperature check station. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained working wash basin, soap, toilet paper, and hand towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV and eating lunch in kitchen. Facility has audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are mounted and fully charged. Facility has supply of PPE. Facility has 2 refrigerators and 2 pantry's 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 Toxins. Facility has a secured location for resident medication and files. LPA observed 5 of 5 resident files. Residents Emergency contact information and Physician's reports are current. Facility has 30 days supply of medications for Residents. Facility has designated visitation area.

No deficiencies noted during todays visit. An exit interview was conducted with Assistant 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: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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