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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700005
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:51:55 PM


Document Has Been Signed on 10/17/2022 12:51 PM - 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:CASEY SIMONFACILITY TYPE:
740
ADDRESS:7707 RUSH RIVER DRIVETELEPHONE:
(916) 392-3510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:72CENSUS: 68DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Casey SimonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/17/22 at 10:00am on a subsequent visit. LPA was allowed entry into the facility that is licensed for a capacity of 72. LPA met with Casey Simon, Administrator and Nicole Hemenover, Resident Service Director, and stated the purpose of todays visit.

LPA toured and inspected the physical plant inside and outside which included cottages to ensure there are no safety hazards to residents. The temperature inside the facility measured in a random amount of rooms and cottages between 73*F and 77 *F which is within the required range of 68-85*F. There are 6 residents currently utilizing hospices services at this time.

The hot water temperature was measured in a random amount of rooms and cottages between 106.3*F and 109.3*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and a pull alarm system in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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