342700005-10-20-2021-27-AS-KHOS-C7ZPK3-20211021112227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700005
Report Date: 10/20/2021
Date Signed: 10/20/2021 02:31:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210519092416

FACILITY NAME:	REVERE COURT		FACILITY NUMBER:	342700005
ADMINISTRATOR:	CHAPPELL, BRENDA		FACILITY TYPE:	740
ADDRESS:	7707 RUSH RIVER DRIVE		TELEPHONE:	(916) 392-3510
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	72	CENSUS: 71	DATE:	10/20/2021
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Brenda Chappell		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not allowing resident to leave the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/20/21 at 1:20pm to conclude the complaint investigation of the above-mentioned allegation. LPA was met by Brenda Chappell and stated the purpose of the visit.

Regarding, allegation, “Facility is not allowing resident to leave the facility”, LPA observed that on 5/3/21, Sacramento City Police Department (SPD) was involved when there was an attempt to remove Resident #1 (R1) from the facility without the knowledge of the Responsible Party (RP), at which time it was deemed there was not a court order to remove R1 from the facility. The Physician Report (LIC602) dated 4/1/21 indicates R1 was diagnosed with vascular dementia. LPA also observed the Advance Health Care Directive dated 12/3/15 which appoints an agent to make healthcare decisions for R1.

LPA observed there are several documents such as petitions for hearings, letters from attorneys, conservatorship requests, narrative charting regarding calls that R1 received and/or made to family.

Unfounded

Estimated Days of Completion: 120

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210519092416

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: REVERE COURT	FACILITY NUMBER: 342700005
	VISIT DATE: 10/20/2021

NARRATIVE

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LPA also observed the Visitor Sign-In and Sign-Out Sheet for the dates of 4/26/21 – 9/30/21 where R1 was receiving visitors. In addition, LPA observed the Resident Off Campus Register from 2/22/21 – 10/1/21. It revealed that R1 left the facility several times with those outings equating to 3 hours or more. LPA interviewed staff #1 (S1-S2) as well as the Executive Director, all of which corroborate that R1 would leave the facility with visitors on outings.

Due to the issue of seeking conservatorship/Power of Attorney/and/or Guardianship the Department has no jurisdiction in those areas. However, the Department does have jurisdiction regarding Title 22 regulations.

Based on interviews and observation of documentation of signatures, times, and dates, R1 left the facility on outings and/or appointments during an 8-month time span.

The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED.

“This agency has investigated the complaint alleging, the above-mentioned allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC9099 (FAS) - (06/04)

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