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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700982
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:20:25 PM


Document Has Been Signed on 01/24/2024 02:20 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, 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: 6DATE:
01/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Krisztina IvascuTIME COMPLETED:
02:30 PM
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On 01/24/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced for a case management visit regarding an Incident Report that was submitted to the Department. LPA met with Administrator Krisztina Ivascu and explained the purpose of the visit.

The department received an incident report on 01/12/24 from the facility that Resident #1 (R1) stated Resident #2 (R2) violated R1s personal rights on 01/09/24.

During today’s visit, LPA conducted interviews and a file review. LPA Ratajczak requested a copy of R2s LIC602. As well as a copy of R1s LIC601, needs and service and LIC602.



Further investigation by Community Care Licensing is required.

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: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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