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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700005
Report Date: 02/26/2021
Date Signed: 02/26/2021 04:09:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:REVERE COURTFACILITY NUMBER:
342700005
ADMINISTRATOR:CHAPPELL, BRENDAFACILITY TYPE:
740
ADDRESS:7707 RUSH RIVER DRIVETELEPHONE:
(916) 392-3510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:72CENSUS: 56DATE:
02/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Brenda ChappellTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (s) (LPA) Victoria Brown and Tirzah Hubbard contacted the facility via telephone to commence an unannounced Tele-visit on 2/26/2021 at 2:45pm due to COVID-19 and pre-cautionary measures. The team met with Brenda Chappell, Executive Director to conduct a Case Management and discussed the purpose of the call and the elements of this type of visit.

This visit is conducted today to inquire about an incident report received by Community Care Licensing (CCL) indicating that resident (R1) received medication that belonged to (R2) which indicates there was a medication error that occurred.

LPAs conducted interviews of the Executive Director and Staff #1 (S1) during this visit.

LPAs requested a copy of the medication Record for both (R1) and (R2) and a revised Incident Report (SIR) and Medication Training Procedures. LPAs also attempted to interview (S2) during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit as further investigation is needed.

An exit interview was conducted with Brenda Chappell via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
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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