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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700676
Report Date: 05/27/2021
Date Signed: 05/27/2021 08:18:38 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20201208081905
FACILITY NAME:SILVANA SENIOR CAREFACILITY NUMBER:
312700676
ADMINISTRATOR:KRISZTINA SILVANA IVASCUFACILITY TYPE:
740
ADDRESS:4748 ROBIN CTTELEPHONE:
(916) 586-4713
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: DATE:
05/27/2021
UNANNOUNCEDTIME BEGAN:
07:33 PM
MET WITH:Tomar Reid, CaregiverTIME COMPLETED:
08:30 PM
ALLEGATION(S):
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Staff did not adequately supervise resident
INVESTIGATION FINDINGS:
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Analyst Mike Reber arrived at the facility today, 5/27/21, and met with caregiver, Tomar Reid to deliver investigation findings to the above stated allegation. During the course of the investigation, this analyst conducted interviews and obtained/reviewed documentation pertinent to the investigation.

Prior to entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore an N-95 respirator and maintained distance during the visit.

**********************************Report continued on LIC 9099C********************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20201208081905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SILVANA SENIOR CARE
FACILITY NUMBER: 312700676
VISIT DATE: 05/27/2021
NARRATIVE
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************************************Report continued from form LIC 9099*************************************

An interview with the licensee on 4/21/21 indicates that staff (S1) was working on Saturday, December 5, 2020. A copy of the LIC 500 obtained indicates that the facility schedules one caregiver on Saturdays. During the incident in question, there were five residents one resident was isolated on the opposite end of the house due to being COVID positive. The remaining four residents were located on the other side of the house. S1 no longer works at the facility and quit shortly after the incident. Analyst obtained training documents from S1 file and S1 does appear to have required training in place. The incident report (LIC 624) obtained indicates that S1 responded when hearing the auditory alarm that the front door had opened. This analyst attempted to contact S1 on two occasions however, S1 phone number is no longer in service. Analyst has been unable to speak with S1 to obtain more details about the incident.

Analyst finds the allegations to be UNSUBSTANTIATED - a finding meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.

Exit interview conducted and a copy of report left with staff. Signature obtained on hard copy of report and placed in facility file.

SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20201208081905

FACILITY NAME:SILVANA SENIOR CAREFACILITY NUMBER:
312700676
ADMINISTRATOR:KRISZTINA SILVANA IVASCUFACILITY TYPE:
740
ADDRESS:4748 ROBIN CTTELEPHONE:
(916) 586-4713
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: DATE:
05/27/2021
UNANNOUNCEDTIME BEGAN:
07:33 PM
MET WITH:Tomar Reid, CaregiverTIME COMPLETED:
08:30 PM
ALLEGATION(S):
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Staff did not provide emergency responders valid resident information
INVESTIGATION FINDINGS:
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In an interview on 4/21/21, the licensee states that she arrived at the facility after being alerted by a staff of a resident (R1) fall. Licensee states that the paramedics made the decision to transport R1 to the hospital for further evaluation. When paramedics requested the residents history, medications and other information, the licensee states she was unable to provide copies due to issues with the facility printer. Licensee offered to provide screen shots from her phone of the requested documents and information. Analyst also obtained a copy of the resident's Physician's Order's for Life Sustaining Treatment (POLST) and the bottom of this document clearly states "SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED".

Based on information interviews conducted and records reviewed, this analyst finds the allegation to be SUBSTANTIATED - a finding that means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. Exit interview conducted. Copy of report and appeal rights provided to staff.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20201208081905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SILVANA SENIOR CARE
FACILITY NUMBER: 312700676
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2021
Section Cited
HSC
1569.74(d)
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Request to forego resuscitative measures; policies to honor requests; conditions; facilities without established policies:
Licensed residential care facilities for the elderly that have not established policies pursuant to subdivision (a), may keep an executed request to forego resuscitative measures form in the resident's file and present it to an emergency medical technician or paramedic when authorized to do so in writing by the resident or his or her legally recognized surrogate decision maker.
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Licensee has created separate binders with resident information to present to paramedics in the event of an emergency.

This deficiency has been cleared during today's visit.
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The request may be honored by an emergency medical technician or by any health care provider as defined in Section 4621 of the Probate Code, who, in the course of professional or volunteer duties, responds to emergencies.

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Based on documents obtained and interviews conducted, the licensee failed to meet this requirement by not providing information to paramedic for continuity of care. This poses a potential health and safety risk to the resident in care.
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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.
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4