312701026-5-20-2022-25-AS-LMUZ-CF9NR5-20220610104052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312701026
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:46:16 PM

Unsubstantiated

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
03/07/2022 and conducted by Evaluator Talwinder Bains

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220307135328

FACILITY NAME:	SILVANA SENIOR CARE 4		FACILITY NUMBER:	312701026
ADMINISTRATOR:	IVASCU, KRISZTINA SILVANA		FACILITY TYPE:	740
ADDRESS:	4738 ROBIN CT		TELEPHONE:	(916) 586-4713
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY:	6	CENSUS: 4	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	04:06 PM
MET WITH:	Andrei Dumitriu		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff lack of care and supervision resulted in resident's unexplained injuries.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/20/2022, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility and met with Administrator, Andrei Dumitriu, to conclude a complaint investigation into the allegation listed above. LPM and LPAs wore surgical masks and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: staff lack of care and supervision resulted in resident's unexplained injuries
** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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 2

Control Number 25-AS-20220307135328

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 4	FACILITY NUMBER: 312701026
	VISIT DATE: 05/20/2022

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 conducted extensive interviews with residents and staff.
LPA reviewed resident records.

Based on facility records review for R1 and interviews conducted, it was found that R1 had not experienced any falls or any injuries while residing at the facility. The resident was admitted to the facility on 02/26/22 and was discharged from the facility 03/03/22 due to a change in condition. R1 was not identified as fall risk resident upon admission to facility on 02/26/22. From R1’s Medical Records review, it was also discovered that R1 was in the hospital multiple times prior to his admission to the facility due to his previous medical condition. Interviews indicated that R1 had a bruise on their hand at the time R1 was admitted to facility. LPA concluded that facility did not provide any actions which would harm or injured R1 while at facility.

Based on interviews conducted by LPAs, observations during inspection, 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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2