306005922-4-15-2022-22-AS-ETAA-CDHQ25-20220415114635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005922
Report Date: 04/15/2022
Date Signed: 04/15/2022 11:46:48 AM

Document Has Been Signed on 04/15/2022 11:46 AM - 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 CARE		FACILITY NUMBER:	306005922
ADMINISTRATOR:	CAMACHO, JESSICA		FACILITY TYPE:	740
ADDRESS:	25455 EL PICADOR LANE		TELEPHONE:	(714) 745-5194
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	04/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Princess Baluyut, Vanessa Rivas Jesseca Camacho		TIME COMPLETED:	11:55 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Princess Baluyut and stated the purpose of this visit. AD Jesseca Camacho arrived during the visit at approximately 10:00 am and provided assistance. The facility is a single level structure and licensed for six non-ambulatory of which 4 can be on hospice. This facility offers Residential Care for the Elderly and Dementia. About 9:54 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed five clients in care and two staff members on the duty. LPA toured the interior and exterior portions of the facility. There were 4 private client's rooms of which 2 could be shared rooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 127.2 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 123.9 degrees Fahrenheit. Bathroom (3) was observed to be in good repair and provided with grab bars and hot water was measured at 126.3 degrees Fahrenheit. Informed Admin regarding the water temperature and adjusted the temperature immediately. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed to be charged and in working order. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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 2

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: 306005922
	VISIT DATE: 04/15/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed gardening tools outside and staff immediately removed and locked up equipment. Laundry room was in good repair were toxins and cleaning supplies were locked. Laundry room leads to a 2 car garage which is used for storage and emergency supplies. Kitchen was in good repair with knifes and cleaning supplies kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. No advisory was issued today.

LPA Tapia conducted an exit interview with AD Jesseca Camacho and copy of this report was explained and left in the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2