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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700982
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:05:40 PM


Document Has Been Signed on 03/21/2024 12:05 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: 4DATE:
03/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator-Krisztina Ivascu TIME COMPLETED:
12:15 PM
NARRATIVE
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On 03/21/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit to follow up on the incident report the department received on 01/02/24. LPA met with Administrator Krisztina Ivascu and explained the purpose of the visit.

On 01/10/24 LPA Ratajczak and LPA Yang conducted a visit regarding the reported incident of R1’s death. During the course of the department’s investigation on this matter, LPA reviewed pertinent documents relevant to the investigation and conducted interviews. While conducting a review of R1’s file it was observed that R1’s file was incomplete with signatures. R1 had a needs and service plan present in file but it was incomplete.

At this time, the Department has not found any indication that the facility’s action contributed to R1’s death therefore the department has no concerns at this time.

Deficiencies are being cited as a result of today’s visit please see LIC809D

Exit interview conducted and a copy of the report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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 03/21/2024 12:05 PM - 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: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Licensee is to come up with a procedure to ensure that all residents files have completed documents and submit plan to LPA Ratajczak by POC due date.
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 resident file was incomplete with documents, which poses a potential health, safety and personal rights risk to persons 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: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2