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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920252
Report Date: 06/29/2026
Date Signed: 06/29/2026 02:23:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2026 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260109150649
FACILITY NAME:REVIVAL SENIOR LIVING, LLCFACILITY NUMBER:
315920252
ADMINISTRATOR:PALAMARCHUK, RICHARDFACILITY TYPE:
740
ADDRESS:3755 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 333-8287
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 0DATE:
06/29/2026
UNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Jonathan GallegosTIME COMPLETED:
02:21 PM
ALLEGATION(S):
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medication mismanagement
facility not following admission agreement
facility not providing proper notice for care increase
facility not providing proper notice for rent increase
facility not notifying POA of emergency events
Facility not following reporting requirements
facility not allowing resident to return to the facility
INVESTIGATION FINDINGS:
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An office meeting was held on Monday June 29, 2026, to deliver findings for a complaint which was received by the Department on 1/9/2026. Present was Regional Manager Harpreet Humpal, Licensing Program Manager Laura Munoz, Licensing Program Analyst Melissa Parks, and Licensee Jonathan Gallegos.

Over the course of the investigation, LPA interviewed the licensee, residents, and other related parties. LPA reviewed admission agreements, invoices, and emails related to R1 and R2’s care. LPA learned the following:

Medication Mismanagement
Based on records reviewed, R1 and R2 moved out of the facility on January 23, 2026. On their move-out day, their responsible party obtained all their medications which were available from Revival. The medications were provided to their new RCFE however it was found that two medications were missing. R1 was missing Levothyroxine and R2 was missing Diltiazem. Additionally, according to R1’s MAR for
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 59-AS-20260109150649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REVIVAL SENIOR LIVING, LLC
FACILITY NUMBER: 315920252
VISIT DATE: 06/29/2026
NARRATIVE
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January 2026, the facility did not administer Levothyroxine on the following dates in January: 9, 10, 13, 14, and 16. R2’s January 2026 MAR states that the Diltiazem was not in a bubble pack nor was there a bottle in stock at the facility yet documentation showed an active order and should have been administered routinely. Based on documentation, the facility did not administer prescribed medications to R1 and R2 as directed by physician.

Not following admission agreement:
Facility not providing proper notice for care increase
According to the signed admission agreement for R1 provided by the licensee, it states ‘Modification of agreement: any changes or modifications to this admission agreement (including changes in service, fees, or policies) must be made in writing and signed by both the resident/representative and the facility”.
During the course of the investigation, Documentation reviewed showed Revival uses a tier system for charging care costs for each resident. On 12/12/2025, Revival increased tier costs without providing 90-day notice to each resident as required by statute. According to documentation that was provided, the tier pricing increased in December 2025, however the licensee did not provide the Department with any notices which were given (and signed) to residents/authorized representatives. The Department obtained an email which was sent to R1’s payee notifying that R1 and R2’s tier cost increase would be effective on 01/01/2026, The email was sent on 12/12/2025 providing a 20-day notice of increase.

Facility not providing proper notice for rent increase
R1 and R2 moved into the facility in September 2025. The licensee billed R1 and R2 for a prorated amount for rent and care at time of move in. Based on the admission agreement, the monthly rate for R1 was $6300 and $1,200 for R2 totaling $7500 for both R1 and R2. In November 2025, the licensee billed R1 and R2 $8,000. The $500 increase in rent was not provided to R1, R2 or their responsible party as required by statute. Furthermore, January invoices dated 12/30/25 show R1 was billed for $5,750 and R2 was billed $6,300 for rent. The licensee did not follow the agreed upon admission agreement and increased monthly charges without required notification time frame.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20260109150649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REVIVAL SENIOR LIVING, LLC
FACILITY NUMBER: 315920252
VISIT DATE: 06/29/2026
NARRATIVE
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Facility not notifying POA of emergency events
Facility not following reporting requirements
R2 was transported to the hospital for a fall on 11/25/2025. R2’s responsible party was not notified by the facility, rather the hospital notified the responsible party when R2 was ready for discharge. R2 was returned back to the facility.
On 11/26/2025, R1 and R2 both sustained falls resulting medical intervention and were taken to the hospital. As a result of R1’s fall, R1 sustained six broken ribs. The facility did not notify R1 and R2’s responsible party when R1 and R2 were sent to the hospital on 11/26/2025. Based on interviews and documentation, R1 and R2’s responsible party was notified by the hospital and not by the licensee that R1 and R2 were sent out. R1 and R2’s responsible party was emailed a detailed incident report regarding the 11/25 and 11/26 falls on December 15, 2025 by the licensee. Additionally, the licensee provided an incident report to the Department regarding the falls via email on December 16, 2025, which falls outside of the 7-day time requirement for notifying licensing. The licensee did not notify R1 and R2’s responsible party or the Department of incidents within the required time frame as documented in statute.

Facility not allowing resident to return to the facility
R1 was admitted to a skilled nursing facility after a hospitalization for a fall resulting in injury in November 2025. Documentation reviewed shows the skilled nursing facility attempted to discharge R1 back to Revival on 12/19/2026 and the licensee refused to take R1 back. According to a fax sent to R1’s primary physician from Licensee, ‘Manzanita Healthcare Center has attempted to discharge R1 for the last 8 days.’ Mr. Gallegos refused R1 to return to the facility citing incomplete paperwork from the SNF. The licensee did not accept R1 back to the facility upon discharge from the SNF.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D.

Exit interview. Copy of report and appeal rights provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Citations on this Visit Report are Under Appeal!

Control Number 59-AS-20260109150649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REVIVAL SENIOR LIVING, LLC
FACILITY NUMBER: 315920252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
06/30/2026
Section Cited
CCR
87465(a)(4)
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1. 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care . . . The plan shall encourage routine medical and dental care . ., by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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The licensee has agreed to submit a plan to include the following: regarding staff training and MAR documentation and procedures for obtaining medication when there are pharmacy obstacles.
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This requirement was not met as evidenced by R1 and R2 not having requirement medication. This poses a direct threat to the health and safety of residents in care.
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Under Appeal
Type B
07/13/2026
Section Cited
CCR
87507(f)
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2. 87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by
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The licensee has agreed to review the admission agreement requirements and will ensure the facility's admission agreement terms are met. The licensee will send an acknowledgement to the Department once he has reviewed the regulations.
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R1 and R2 not being provided written and signed agreement for any changes. This poses an indirect threat to the health and safety of 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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Citations on this Visit Report are Under Appeal!

Control Number 59-AS-20260109150649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REVIVAL SENIOR LIVING, LLC
FACILITY NUMBER: 315920252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/13/2026
Section Cited
CCR
1569.655(a)
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§1569.655 Increase in fee rates for elderly residents; 90 days’ written notice . . . (a) . . . increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.

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The licensee will send an acknowledgement to the Department once he has reviewed the regulations.
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This requirement was not met as evidenced by the facility changing care tier costs and rent without proper notice. This poses an indirect threat to the health and safety of residents in care.
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Under Appeal
Type B
07/13/2026
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly . . .
(8) To have their representatives regularly informed by the licensee of activities . . . This requirement was not met as evidenced by R1 and R2 being sent to the hospital
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The licensee will submit a statement of understanding regarding reporting requirements.
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and the facility did not notify the responsible party. This poses an indirect threat to the health and safety of 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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Citations on this Visit Report are Under Appeal!

Control Number 59-AS-20260109150649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REVIVAL SENIOR LIVING, LLC
FACILITY NUMBER: 315920252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/13/2026
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency . . . (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events . . .
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The licensee will submit a statement of understanding regarding the requlation for notifying the Department of unsual incidents.
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This requirement was not met as evidenced by the Department did not receive incident reports regarding R1 and R2's hospitalization within the required time frame. This poses an indirect threat to the health and safety of residents in care
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The licensee agrees to submit a statement of understanding regarding the regulations for accepting a resident back after a SNF or hospital discharge.
Under Appeal
Type B
07/13/2026
Section Cited
CCR
87468.2(20)
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Additional Personal Rights of Residents in Privately Operated Facilities
(20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations . . . This requirement was not met as evidenced R1 not being allowed back to the facility once ready for SNF discharge. This poses an direct threat to the heatlh and safety of 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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2026 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260109150649

FACILITY NAME:REVIVAL SENIOR LIVING, LLCFACILITY NUMBER:
315920252
ADMINISTRATOR:PALAMARCHUK, RICHARDFACILITY TYPE:
740
ADDRESS:3755 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 333-8287
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 0DATE:
06/29/2026
UNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Jonathon GallegosTIME COMPLETED:
02:21 PM
ALLEGATION(S):
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Administrator physically assaulted resident
Administrator speaking inappropriately to resident
INVESTIGATION FINDINGS:
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An office meeting was held on Monday June 29, 2026, to deliver findings for a complaint which was received by the Department on 1/9/2026. Present was Regional Manager Harpreet Humpal, Licensing Program Manager Laura Munoz, Licensing Program Analyst Melissa Parks, and Licensee Jonathan Gallegos.

Over the course of the investigation, LPA interviewed the licensee, residents, and other related parties. LPA learned the following:

Administrator physically assaulted resident
According to the complaint details, Mr. Gallegos was assisting R2 during the middle of the night on 1/13/2026. While doing so, Mr. Gallegos became upset with R2 and assaulted R2. Additionally, information provided that Mr. Gallegos speaks inappropriately to residents in care. Interviews were conducted regarding the incidents. Based on interviews conducted and resident’s diminished capacity,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20260109150649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REVIVAL SENIOR LIVING, LLC
FACILITY NUMBER: 315920252
VISIT DATE: 06/29/2026
NARRATIVE
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the Department was unable to determine if the licensee physically assaulted and/or spoke inappropriately with residents in care.

Based on information obtained during the investigation, LPA finds the allegations to be
UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred

Exit interview conducted. A copy of this report was provided to the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8