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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700676
Report Date: 05/27/2022
Date Signed: 05/27/2022 05:07:27 PM

Substantiated


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
11/04/2021 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20211104140114
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: 5DATE:
05/27/2022
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Andrei Dumitriu, AdministratorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Staff gave paramedics file for resident with another resident's medication sheet.
INVESTIGATION FINDINGS:
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On 5/27/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Andrei Dumitiriu, to conclude a complaint investigation into the allegation listed above. LPA wore an N-95 mask.

During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Staff gave paramedics file for resident with another resident's medication sheet.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
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 5
Control Number 25-AS-20211104140114
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: 05/27/2022
NARRATIVE
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Interview with staff member (S1), conducted on 11/10/2021, indicated that paramedics arrived at the facility to assist with transferring resident (R1) to the hospital on 11/4/2021. S1 stated that they gave paramedics R1's file. However, as S1 was making copies of documents from R1's file, they noticed that the files copied were not for R1. S1 stated that they attempted to correct the matter by finding the correct files for R1 and making copies for paramedics. However, paramedics refused to wait for S1 and left with the copies initially made before S1 acknowledged the error.

During inspection conducted on 11/10/2021, LPAs Michael Hood and Angela Hood conducted a review of R1's file. LPAs observed that R1 had a Medication List with a name that was not R1's. Interview with Administrator, Andrei Dumitriu, indicated that no residents at the facility shared the name of what was indicated on the Medication List in R1's file. Administrator stated that the hospice agency providing services to R1 was responsible for placing the wrong Medication List in R1's file.

During inspection conducted on 5/27/2022, LPA Michael Hood conducted a review of R1, R2, R3, R4, R5, and R6's file. LPA did not observe any other documents mixed with another resident's file, but did observe at least one required document missing from each resident's file.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/04/2021 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20211104140114

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: 5DATE:
05/27/2022
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Andrei Dumitriu, AdministratorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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2
3
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9
Staff gave paramedics the wrong resident file.

Staff may not be administering the right medications to the resident.
INVESTIGATION FINDINGS:
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13
On 5/27/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Andrei Dumitriu, to conclude a complaint investigation into the allegations listed above. LPA wore an N-95 mask.

During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Staff gave paramedics the wrong resident file.

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
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 5
Control Number 25-AS-20211104140114
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: 05/27/2022
NARRATIVE
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Interview with staff member (S1), conducted on 11/10/2021, indicated that paramedics arrived at the facility to assist with transferring resident (R1) to the hospital on 11/4/2021. S1 stated that they gave paramedics R1's file. However, as S1 was making copies of documents from R1's file, they noticed that the files copied were not for R1.

During inspection conducted on 11/10/2021, LPAs Michael Hood and Angela Hood conducted a review of R1's file. LPAs observed that R1 had a Medication List with a name that was not R1's.

Based on interview with S1 and LPAs observations of R1's file, it is determined that paramedics received the correct facility file for R1, despite not all documents belonging to R1.

Allegation: Staff may not be administering the right medications to the resident.

During inspection conducted on 5/27/2022, LPA Michael Hood conducted a medication count for R2, R3, and R4, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPA did not observe any errors when comparing medication count with CSMs for R2, R3, and R4.

Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20211104140114
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: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
87506(a)
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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Administrator agrees to complete the files missing from the file review conducted for residents on 5/27/2022. Administrator will also complete a statement of understanding regarding regulation 87506 and resident records.
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Based on interviews conducted and records reviewed, facility did not ensure that resident files were complete and did not ensure R1's documents were seperate from another individual, which poses a potential health, safety, and personal rights risk to residents in care.
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Administrator will submit requested documents and statement of understanding to department by POC due date.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5