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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005494
Report Date: 06/17/2024
Date Signed: 06/17/2024 03:39:57 PM


Document Has Been Signed on 06/17/2024 03:39 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 MANORFACILITY NUMBER:
306005494
ADMINISTRATOR:FADDOUL, LACYFACILITY TYPE:
740
ADDRESS:425 ARCHER STTELEPHONE:
(949) 682-5229
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 6DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Catalina FeregrinoTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual inspection. LPA arrived at the facility was greeted and granted entry by Catalina Feregrino, caregiver. Six residents currently reside at this location and one resident is on hospice. LPA spoke to Lacy Faddoul, Administrator via telephone call.

LPA accompanied by caregiver began the tour of the inside and outside of the facility. There is a minimum of one week of non-perishable foods and two days of perishable foods available. There is additional food storage in attached garage in refrigerator. LPA checked if medications are centrally stored in a safe locked cabinet location in kitchen. LPA reviewed medication. Residents’ medication was labeled and stored inaccessible to the residents. The facility is maintained at a comfortable temperature. The hot water temperature measured 114.9 Fahrenheit degrees in residents’ restrooms. Restrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility has an available a clean supply of linen. LPA inspected residents’ bedroom which had sufficient lighting to ensure safety and comfort. Storage space is provided for residents. LPA observed hospice nurse at residents bedside. LPA inspected and observed that toxic chemicals, cleaning solutions and disinfectants are locked and inaccessible to residents in a storage closet located in the hallway. LPA toured the second floor of the facility, which is inaccessible to residents in care. There are no residents residing on the second floor. Smoke detectors and alarms were tested and operational. LPA toured the outside parameters of facility and observed outdoor passageways are free of obstruction. Disaster drills are conducted every quarter. Facility has a covered patio with seating for residents’ enjoyment. LPA spoke with alert residents regarding the quality of their care. LPA reviewed staff, fingerprint records. All employees have a criminal record clearance. During the inspection, LPA reviewed three resident records and two staff

Continued on LIC809-C
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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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 MANOR
FACILITY NUMBER: 306005494
VISIT DATE: 06/17/2024
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records. All the required documentation was present and current in the files reviewed. LPA reviewed the P&I funds for resident, LPA observed lock boxes with funds in the kitchen. LPA as a reminder provided annual fee dues information.

Based on the observations made during today’s visit, no deficiencies were noted in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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