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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700005
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:47:59 AM


Document Has Been Signed on 06/20/2024 11:47 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:REVERE COURTFACILITY NUMBER:
342700005
ADMINISTRATOR:IRENE CHARNELLFACILITY TYPE:
740
ADDRESS:7707 RUSH RIVER DRIVETELEPHONE:
(916) 392-3510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:72CENSUS: 71DATE:
06/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nicole HemenoverTIME COMPLETED:
12:00 PM
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On 6/20/24 at 11:00am Licensing Program analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address concerns of recent falls within the last week at the facility. LPA met with RSC Nicole Hemenover, LVN to discuss recent falls and to determine if there are any connections or issues present and to provide support.

LPA reviewed recent falls and incident reports and observed the residents. LPA met with one resident who provided statements regarding their most recent fall at the facility. LPA observed all recently reported falls have varying circumstances and occurred at different times and locations at the facility.

No deficiencies were observed during today's inspection.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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