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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002859
Report Date: 04/19/2023
Date Signed: 04/19/2023 12:38:30 PM

Document Has Been Signed on 04/19/2023 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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: 5DATE:
04/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Krisztina Ivascu, AdministratorTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Krisztina Ivascu, Administrator, during today's inspection.

LPA was informed by administrator that on the night of 4/12/23 and/or morning of 4/13/23 resident left the facility unassisted. Caregivers found that resident was missing on the morning of 4/13/23. Local police were contacted and administrator was informed resident was found wandering in the community and was taken to residents family members house. Administrator contacted family member, and resident was returned to the facility on 4/13/23. Resident had no injuries and resident has a pending doctor's appointment.

In addition, LPA found facility night staff are sleeping in the common living room. Administrator stated a staff room will be built pending city building permits.

Deficiencies cited on 809-D.

Exit interview and appeal rights given.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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 04/19/2023 12:38 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 04/19/2023 at 12:13 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SILVANA SENIOR CARE 5
FACILITY NUMBER: 315002859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2023
Section Cited
CCR
87705(c)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Administrator has made a doctor appointment for R1. In addition administrator to submit to CCL their plan on supporting R1's care needs with an updated needs and service plan.
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Based on interviews conducted, the Licensee did not ensure that resident (R1) was unable to leave the facility unassisted which posed an immediate health and safety risk to residents in care.
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Type B
04/28/2023
Section Cited
CCR87307(a)

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87307 Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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Administrator states they applied for city building permits. Administrator to submit to CCL a new facility sketch of where the staff room will be. Facility sketch to be sent into CCL by 4/28/23.
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Based on interviews and facility tour, staff are sleeping in the common living area which poses a potential health and safety 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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023


LIC809 (FAS) - (06/04)
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