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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700005
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:00:49 PM


Document Has Been Signed on 01/18/2024 12:00 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
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: 67DATE:
01/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Irene CharnellTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jamie Ivey Canady visited the facility unannounced and met with Administrator Irene Charnell and explained the reason for today's visit.

According to Incident Report received by the Department from the facility on 1/15/2024, R1 is a member of facility Day Club. R1 was reported AWOL from the facility day club program at approximately 4:45 pm on 1/10/2024. According to facility document review, R1 had last been seen on the facility grounds by facility staff at 4:30pm. R1 was located on the same road as the facility, but outside the grounds next to a busy street at approximately 4:50pm by facility staff. According to facility incident report R1 was missing from facility grounds for less than 10 minutes.

Based on facility resident file review, on page 2 of R1 Preplacement Appraisal Form LIC603, under services needed "Needs special observation/night supervision (due to confusion, forgetfulness, wandering), Yes is checked with a handwritten note "Yes to all. Constant Wandering".

According to facility file document review, and facility invoice, facility had construction and repairs performed on the facility on 1/10/2024. Based on incident report, facility gate had been left slightly ajar by construction staff. It was learned that R1 accessed the outside of the facility grounds via the open section in the gate that had been left open by construction staff. However, based on Title 22 regulations, licensee responsibility for health and safety of R1 based on facility service agreement was not fulfilled.

Therefore, based on Title 22 regulations, deficiencies cited.

Exit interview held and copy of report given to Administrator Irene Charnell.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/18/2024 12:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: REVERE COURT
FACILITY NUMBER: 342700005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
01/18/2024
Section Cited
CCR
87705(a)(h)

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87705 Care of Persons with Dementia (a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia...(h)Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.This was not met as evidenced by:
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Licensee states as a plan of correction no keys will be given to outside vendors. A training withthe maintenance team that this is the new protocol going forward will be conducted no later than (NLT) 1/19/2024 and proof of training will be forwared to LPA via email.
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Based on facility incident report and documentation, the licensee did not ensure the facility gates stayed locked during construction services. This posed an immediate health and safety issue to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2