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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 11:50:05 AM


Document Has Been Signed on 01/10/2024 11:50 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 - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH: Interim Administrator- Geta PopTIME COMPLETED:
11:50 AM
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On 01/10/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility unannounced for a case management visit regarding an Incident Report that was submitted to the Department. LPAs met with Interim Administrator, Geta Pop, and explained the purpose of the visit.

The department received an incident report on 01/02/24 from the facility indicating medical emergency for R1 on 12/30/2023. The incident report stated that R1 was sent to the hospital and the facility was notified R1 passed away later on the day. Cause of death is unknown at this time.



During today’s visit, LPAs conducted interviews regarding this incident. LPAs requested a copy of R1's file. Interim Administrator stated R1's file was at Administrator's home, but it can be retrieved by staff. Staff arrived afterwards with R1's file, where copies were made for LPAs.

This incident will remain under review by the Department until further notice.

Exit interview conducted and a copy of the report 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)
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