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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700005
Report Date: 06/30/2022
Date Signed: 06/30/2022 10:58:43 AM


Document Has Been Signed on 06/30/2022 10:58 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
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: DATE:
06/30/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
10:00 AM
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An Office Meeting was conducted on 6/30/2022 via Microsoft Teams with the Sacramento South Regional Office at 9:30am. The purpose of this meeting is to discuss and review procedures put in place to ensure the facility remains in substantial compliance while participating in the Mitigation of Major Hip Injury due to fall in an at-risk, Older Adult population with a wearable smart belt. (Tango Belt Study). Present in the meeting is Assistant Program Administrator (APA) Stacy Barlow, Acting Regional Manager/Licensing Program Manager (RM/LPM) Liza King, Licensing Program Analyst (LPA) Victoria Brown, Representatives of Active Protective Technologies Inc. Wamis Singhatat, CEO, and Rebecca Tarbert Director of Clinical Programs/Physical Therapist, Representatives of Chancellor Health Care of California VIII Inc.: Brenda Chappell, Executive Director, Nicole Hemenover, Resident Service Director, and Casey Simon, Director of Community Relations.
Facility is requesting a waiver to participate in the Tango Belt Study.

Subject areas discussed during the meeting:
-Specific such as how study became involved with the facility
-Purpose of the study
-Participation requirements
-Training being provided to staff
-Length of time study to be conducted
-Confidentiality protocols/HIPPA
-Resident safety
-Wear time of belt and/or replacement

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted 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: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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