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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002859
Report Date: 10/19/2022
Date Signed: 11/04/2022 09:17:43 AM

Document Has Been Signed on 11/04/2022 09:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 5FACILITY NUMBER:
315002859
ADMINISTRATOR:SANDOR IVASCU, MIRELFACILITY TYPE:
740
ADDRESS:2505 CORIN DR.TELEPHONE:
(916) 966-8562
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
10/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Mirel Ivascu TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program manager (LPM) Laura Munoz arrived at the facility unannounced on 10/19/22 and met with administrator Mirel Ivascu , Prior to the visit , LPA and LPM completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA and LPM wore the following Personal Protective Equipment (PPE) during today's visit-surgical masks.
LPA and LPM were screened by facility staff upon entry.

On 08/02/2022, the department conducted a complaint investigation at which time the department had requested R1s admission agreement and other related documents and facility needed to submit those documents by 08/07/22. As of this date, the facility did not submit requested documentation therefore, deficiency Type-B is being cited per Title 22 ,CCR, Regulation -87755(c).

Appeal rights provided, copy of the report left at facility. Exit Interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2022 09:17 AM - It Cannot Be Edited


Created By: Talwinder Bains On 10/19/2022 at 04:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SILVANA SENIOR CARE 5
FACILITY NUMBER: 315002859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2022
Section Cited
CCR
87755(c)

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87755-Inspection Authority of the Licensing Agency.(c)-The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. This requirement was not met as evidenced by:
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Licensee to review section 87755 for Inspection Authority of the Licensing Agency and send a letter of understanding to Community Care Licensing by 11/03/22 by fax.
Additionally, licensee to ensure that facility will provide any requested documents to department in future.
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Licensee did not provide requested documents to department as requested on 08/02/22 for R1s admission agreement. This poses a potential health, safety, and/or personal rights risk to residents 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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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