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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920252
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:15:55 PM

Document Has Been Signed on 03/06/2025 03:15 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:REVIVAL SENIOR LIVING, LLCFACILITY NUMBER:
315920252
ADMINISTRATOR/
DIRECTOR:
PALAMARCHUK, RICHARDFACILITY TYPE:
740
ADDRESS:3755 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 333-8287
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Admin - Richard Palamarchuck, Licensee - Jonathan GallegosTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Graham Gunby arrived on Thursday March 6, 2025 to conduct an announced pre-licensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. All files contained the required paperwork. This facility has a fire clearance for 6 (six) nonambulatory, of which 2 (two) can be on hospice. Facility has all required postings in the entry.

LPAs toured the facility with the licensee and administrator. The following areas were inspected for compliance: kitchen, backyard, resident bedrooms, bathrooms, and common areas. Facility has current fire extinguisher and a full first aid kit. Medications will be kept locked in a cabinet. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents.

Component III has been completed at this time.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with licensee and a copy of this report will be left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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