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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700982
Report Date: 04/01/2021
Date Signed: 04/01/2021 11:41:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SILVANA SENIOR CARE 3FACILITY NUMBER:
342700982
ADMINISTRATOR:IVASCU, KRISZTINAFACILITY TYPE:
740
ADDRESS:7662 COPPER COVE PL.TELEPHONE:
(916) 586-4713
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 0DATE:
04/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Krisztina IvascuTIME COMPLETED:
11:50 AM
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On April 1, 2020, at 10 AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone to conduct an announced Pre-Licensing Tele-Inspection visit due to COVID-19 and pre-cautionary measures.

LPA was allowed entry into the facility via Facetime that will be licensed for a capacity of six (6). LPA toured the facility with Administrator, Krisztina Ivascu. The indoor and outdoor passageways were free of obstruction. Upon entering the facility LPA observed COVID-19 signages.

The facility has a total of six (6) bedrooms and two (2) and half bathrooms. One bedroom is being used as staff's room. There is an exit in bedroom number one (1) and four (4) that leads to the backyard. LPA notified Administrator that no locks are permitted on bedroom number 1 and 4. A door alarm is to be set up in the bedrooms with an exit to the backyard for Dementia residents. LPA observed the living room, dining room, kitchen, family room, residents' bedrooms, bathrooms, laundry room, and backyard. LPA observed knives/sharps were locked in the kitchen right by dish washer. LPA observed toxic and cleaning supplies locked underneath the kitchen sink. LPA observed the require furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. Hot water temperature was measured in residents' bathroom at 107 degrees Fahrenheit. First aid kit was completed with bandages, tweezers, scissors, and thermometer located in the hallways cabinets. LPA observed centrally stored medication areas to be locked in the hallway cabinets along with staff and residents' files.

LPA observed two (2) fire extinguisher in the kitchen and bedroom hallways. Fire extinguisher is to be expired on February 2022. LPA observed fire detectors and carbon monoxide.

Component III presentation conducted with Administrator, Krisztina Ivascu.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with Administrator, Krisztina Ivascu, via telephone and a copy of this report will be provided to the facility via email. Report is to be signed and return to LPA via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
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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