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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920252
Report Date: 02/13/2026
Date Signed: 02/13/2026 01:03:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250613085822
FACILITY NAME:REVIVAL SENIOR LIVING, LLCFACILITY NUMBER:
315920252
ADMINISTRATOR:PALAMARCHUK, RICHARDFACILITY TYPE:
740
ADDRESS:3755 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 333-8287
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 1DATE:
02/13/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee - Jonathan GallegosTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff not meeting resident's needs
Staff not meeting resident's prescribed dietary needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 02/13/2026 to complete and deliver findings to a complaint received on 06/13/2025. LPA met with Licensee, Jonathan Gallegos and explained the purpose of the visit.

Throughout the course of the investigation, the department conducted interviews and record reviews.

Please continue to LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 59-AS-20250613085822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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, LLC
FACILITY NUMBER: 315920252
VISIT DATE: 02/13/2026
NARRATIVE
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Staff Not Meeting Resident’s Medical Needs

Based on interviews with staff and review of facility records, it was determined that the facility did not have a documented diabetes care plan for Resident 1 (R1). Records indicate R1 has multiple medical diagnoses of diabetes.

The Admission Agreement signed on 04/25/2025 listed a monthly charge for “diabetic management.” However, when requested, facility staff were unable to produce a diabetes care plan outlining how R1’s diabetic needs were monitored or managed.

Staff member S3 stated that R1’s blood sugar is checked daily; however, no blood glucose monitoring logs or documentation were available for review to support this statement. The LPA observed that R1’s diabetes was not addressed in the Appraisal/Needs and Services Plan on file.

Additionally, the Physician’s Report (LIC 602) dated 04/18/2025 indicated that R1 requires a specialized diet. When requested, the facility was unable to provide a diabetic or specialized menu specific to R1.

Staff Not Meeting Resident’s Prescribed Dietary Needs

Based on record review and staff interviews, it was determined that the facility did not ensure R1’s prescribed dietary needs were met. The Physician’s Report (LIC 602) dated 04/18/2025 documented that R1 is diagnosed diabetes required a specialized diet and assistance with medical needs.

The Admission Agreement signed on 04/25/2025 identified Diabetic Management under other personal care needs. Despite this, when the LPA requested documentation of a diabetic diet or diabetes care plan, staff member S1 stated that no such plan existed.

Staff member S3 reported that blood glucose monitoring was conducted using a glucose monitor; however, no logs or records were available to verify ongoing monitoring. Additionally, the facility was unable to provide a sample menu or documentation demonstrating that R1 was receiving meals consistent with a prescribed diabetic or modified diet.

Deficiencies cited on LIC9099-D

Exit interview conducted. Copy of report was provided to licensee.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250613085822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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, LLC
FACILITY NUMBER: 315920252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2026
Section Cited
CCR
87457(c)(2)
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87457(c)(2) If an initial appraisal or any reappraisal identifies an individual resident service need which is not being met by the general program of facility services, advice shall then be obtained from a physician, social worker, or other appropriate consultant to determine if the needs can be met by the facility.This requirement was not met as evidence by:
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Licensee will submit a statement of understanding for section 87457(c)(2) by email to LPA by 03/13/2026.
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Based on interview and record review, the facility did not develop and maintain a documented plan of care addressing R1’s diabetes management and related medical needs, despite identifying diabetic management as a service provided which poses a potential health and safety risk to residents in care.
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Type B
03/13/2026
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements (b)The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding for section 87555(b)(7) by email to LPA by 03/13/2026.
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Based on LPA interviews and records review it was determined that The facility failed to provide and document a physician-prescribed modified diet and failed to maintain records demonstrating monitoring of R1’s diabetic condition which poses a potential health and safety risk to residents 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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250613085822

FACILITY NAME:REVIVAL SENIOR LIVING, LLCFACILITY NUMBER:
315920252
ADMINISTRATOR:PALAMARCHUK, RICHARDFACILITY TYPE:
740
ADDRESS:3755 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 333-8287
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 1DATE:
02/13/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee - Jonathan GalloTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Air conditioner not working and licensee not repairing it.
INVESTIGATION FINDINGS:
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On 06/13/2025 the Department received a complaint with the allegation cited above. On 06/16/2025 and 07/29/2025 the Department conducted an inspection of the facility's air conditioning unit located at the end of the common area. Based on observation, the air conditioning unit was operating and in good condition. There was no observation of the air conditioning unit being inoperable or a danger to residents in care.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4