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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002898
Report Date: 09/25/2024
Date Signed: 09/25/2024 01:47:25 PM

Document Has Been Signed on 09/25/2024 01:47 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:SILVANA SENIOR CARE 6FACILITY NUMBER:
315002898
ADMINISTRATOR/
DIRECTOR:		IVASCU, MIRELFACILITY TYPE:
740
ADDRESS:7040 LUDLOW DRTELEPHONE:
(916) 797-3405
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Krisztina Ivascu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Krisztina Ivascu.

LPA arrived to discuss an incident report that was received. Resident was sent out to the emergency department due to a change of condition and pressure injuries. Resident is currently admitted to a SNF and is pending return to facility.

During the file review LPA observed resident's LIC602 was completed in August 2023 and there was no doctor signature. Resident was admitted to the facility in August 2024. Due to file review, deficiencies have been cited on 809-D.

Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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Document Has Been Signed on 09/25/2024 01:47 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 09/25/2024 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SILVANA SENIOR CARE 6
FACILITY NUMBER: 315002898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
87458(a)

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87458 Medical Assessment. (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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Administrator agrees to send into LPA a statement of understanding for regulation 87458. Statement to be sent into CCL on 10/11/24.
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This requirement is not met as evidence by: Based on record review the licensee did not obtain a signed, and current medical assessment prior to accepting resident which poses a potential health, safety 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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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