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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005744
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:31:11 PM

Document Has Been Signed on 12/03/2024 01:31 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SILVER LINING CARE HOMEFACILITY NUMBER:
347005744
ADMINISTRATOR/
DIRECTOR:		EVELINA AND PAVEL MAGUREANFACILITY TYPE:
740
ADDRESS:8189 PLUMERIA AVENUETELEPHONE:
(916) 241-9186
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Evelina MagureanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility unannounced on 12/03/2024 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and six (6) bathrooms for resident use. LPAs observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 115.5 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on site. LPAs observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPAs observed the backyard and perimeter of the care home to be free of clutter and debris. LPAs observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. LPAs reviewed five (5) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy.

As a result of this visit, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on 809-D pages.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
Anthony PerezTELEPHONE: (323) 485-4915
Cassandra MikkelsonTELEPHONE: 916-709-6830
DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 5
Document Has Been Signed on 12/03/2024 01:31 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SILVER LINING CARE HOME
FACILITY NUMBER: 347005744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year (...)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and LPAs observations, the licensee did not ensure that a record of Centrally Stored Medications was maintained in accordance with Title 22, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Licensee will complete Centrally Stored Medication record for all residents' medications and submit 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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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony PerezTELEPHONE: (323) 485-4915
Cassandra MikkelsonTELEPHONE: 916-709-6830

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024

LIC809 (FAS) - (06/04)
Page: 2 of 5