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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312701026
Report Date: 11/22/2022
Date Signed: 12/06/2022 10:45:30 AM

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
05/20/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20220520084919
FACILITY NAME:SILVANA SENIOR CARE 4FACILITY NUMBER:
312701026
ADMINISTRATOR:IVASCU, KRISZTINA SILVANAFACILITY TYPE:
740
ADDRESS:4738 ROBIN CTTELEPHONE:
(916) 586-4713
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:CaregiversTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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**Amended**
Staff did not provide proper care and supervision to residents in care.
INVESTIGATION FINDINGS:
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** Amended**

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/22/22 to deliver complaint findings. LPA met with caregivers and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Administrator arrived to assist with the visit

The department reviewed client/resident records and conducted interviews and inspections.
The department finds that the allegations cited above are substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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 7
Control Number 25-AS-20220520084919
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: 11/22/2022
NARRATIVE
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** Amended**

Records reviews conducted 10/14/22 by LPA Mknelly for R1 found that R1 did not have a care plan documented. The facility only had a pre-appraisal on file. The pre-appraisal, from 11/10/21, identified R1 as experiencing Dementia with short and limited long term memory, is active with a use of a walker, occasionally needs assistance with transfers. R1’s physician report dated 11/2/21 notes Dementia with confusion and aggression at times. R1’s injuries, supervision level and strategies for her to move safely were not communicated to staff in a written care plan. Interviews with staff found that staff had a informal plan of attending to R1 (and they reported to engage with R1 often). However, the strategy by staff was to remind R1 to move safely and call for assistance as needed. R1’s poor memory was not accounted for in the plan and therefore did not address R1’s care and supervision needs. 87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Administrator . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 25-AS-20220520084919
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2022
Section Cited
CCR
87463(a)
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Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met based on records review and interviews. This posed a potential risk to resident.
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Licensee will submit completed and current needs and services plan for all current residents in care (as of 11/22/22) by the POC date of 12/13/22.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
05/20/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20220520084919

FACILITY NAME:SILVANA SENIOR CARE 4FACILITY NUMBER:
312701026
ADMINISTRATOR:IVASCU, KRISZTINA SILVANAFACILITY TYPE:
740
ADDRESS:4738 ROBIN CTTELEPHONE:
(916) 586-4713
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:CaregiversTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide proper medication assistance to resident in care
Staff do not perform proper hand hygiene
Staff left resident in soiled clothing for extended time
Staff did not notify resident’s authorized representative of resident’s change in condition
Staff does not respond to resident’s call for help
Staff are not meeting resident’s hygiene needs
Resident sustained multiple injuries while in care.
Resident sustained a fracture while in care.
INVESTIGATION FINDINGS:
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On 11/22/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met Administrator. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened with temperature at the facility.

The Department conducted records review and extensive interviews.
The Department is unable to find and or meet the preponderance, per policy.

Neither records, interviews nor LPA's limited observations uncovered evidence to support the allegations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 25-AS-20220520084919
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: 11/22/2022
NARRATIVE
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** Amended**
The event of R1 found to have a medication still in their mouth following a medication time was an unusual event for that resident.
LPAs observed staff to wash their hands and interview statements are that staff are disciplined in hand hygiene
Residents alleged to be in soiled clothing for extended time was reported for a time when R1 was in the hospital. No additional incidents were found. Inspections found the facility odor free
Staff interviews, records found notification of resident’s authorized representative of resident’s change in condition were regular and often.
Interviews of residents did not support that staff do not respond to resident’s call for help
Staff interviews and records reviews found that resident’s hygiene needs appear to be met.

Allegations Resident sustained multiple injuries while in care and Resident sustained a fracture while in care found that R1 did, in fact, sustain injuries and a fractured wrist (3/27/22) while at the facility. However, the allegation, as written, does not attribute fault to staff care or lack of care. R1’s fracture was due a unwitnessed fall from bed as reported by R1 to staff. R1 stated that they informed staff of pain. Medical care was sought timely. R1’s other bruises and skin tears often were unwitnessed events when R1 was moving independently throughout the home. Therefore no violation is noted for these events at this time.


As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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.

Report provided.
On 12/6/22, LPA emailed licensee amended report to licensee for signature to be in facility file
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
05/20/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20220520084919

FACILITY NAME:SILVANA SENIOR CARE 4FACILITY NUMBER:
312701026
ADMINISTRATOR:IVASCU, KRISZTINA SILVANAFACILITY TYPE:
740
ADDRESS:4738 ROBIN CTTELEPHONE:
(916) 586-4713
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:CaregiversTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is unkempt
Staff did not report a facility outbreak to appropriate parties
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/15/21 to provide complaint findings. LPA met with staff and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPAs reviewed resident records, facility records, conducted interviews and three facility inspections (5/24/22, 7/27/22 and 10/14/22).
The department finds that facility met Tittle 22 requirements.
At the three (3) unannounced visits during this investigation the home was clean and odor free.
The facility did not experience an outbreak as alleged. One of the licensee’s other homes had a properly
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 25-AS-20220520084919
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: 11/22/2022
NARRATIVE
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 reported outbreak but one did not occur at this residence during the period alleged.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7