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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700982
Report Date: 01/10/2024
Date Signed: 01/10/2024 11:51:20 AM


Document Has Been Signed on 01/10/2024 11:51 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SILVANA SENIOR CARE 3FACILITY NUMBER:
342700982
ADMINISTRATOR:MITITI, BIANCAFACILITY TYPE:
740
ADDRESS:7662 COPPER COVE PL.TELEPHONE:
(916) 586-4713
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 5DATE:
01/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Interim Administrator- Geta PopTIME COMPLETED:
11:50 AM
NARRATIVE
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On 01/10/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility unannounced to conduct a cause management visit. LPAs met with Interim Administrator, Geta Pop, who stated Administrator, Krisztina Ivascu, designated her as interim Administrator while Administrator was out of the state.

It was discussed on the phone with Administrator, Krisztina Ivascu, the current Administrator on file, Bianca Mititi, is no longer working at the facility. Administrator stated that documents were submitted to Licensing to change Administrator to Krisztina Ivascu.

LPAs conducted a file review on Guardian to confirm if S1 is cleared and associated to the facility. File review revealed S1 does not have a fingerprint clearance transfer. Interim Administrator stated Administrator has been out of state since 01/09/24 and will return on 01/14/24.

LIC 9182 was completed for fingerprint transfer, LPAs confirmed with Administrator on the phone if LIC 9182 can be signed by Interim Administrator in Administrator's behalf.

Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/10/2024 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SILVANA SENIOR CARE 3
FACILITY NUMBER: 342700982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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Licensee verbally approved LIC 9182 to be signed by interim Administrator.
LPAs associated S1 to the facility immediately.
Licensee will submit a compliance statement to LPA Ratajczak that all individuals are to be associated to the facility prior to residenting, working and/or volunteering at the facility.
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Based on interview and record review, the licensee did not comply to the section cited above as LPAs observed S1 working at the facility without a fingerprint transfer which poses a potential 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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
LIC809 (FAS) - (06/04)
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