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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920252
Report Date: 03/18/2026
Date Signed: 03/18/2026 03:21:38 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
03/17/2026 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260317095423
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: DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Neha Sharma and Lusi TubamasiTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff left resident unattended
Staff not answering facility phone
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday March 18, 2026 to conduct a complaint investigation regarding the above allegations. LPA met with staff Neha Sharma and explained the purpose of the visit. Staff called the licensee, Jonathan Gallegos who indicated he was unable to come to the facility during today's visit.

LPA interviewed S1 regarding the allegations. LPA learned the following: On Monday March 16, 2026, S1 was the only staff on duty at the facility. S1 needed to complete an appointment outside of the facility. At this time, R1 was being visited by a private duty caregiver. S1 let R1's private caregiver know they were leaving the facility. According to S1, they were absent from the facility for approximately 2 hours. When S1 returned, R1's family and private duty caregiver were at the facility. Additionally, since there were no staff at the facility, there was no one present to answer the facility phone. Although the family had a private caregiver on site with R1, it is the responsiblity of the licensee to ensure facility staff are present in the facility 24 hours a day to provide care and supervision to resident's in care. CONT on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
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 3
Control Number 59-AS-20260317095423
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: 03/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities . . . (4) To care, supervision, and services that meet their individual needs and are
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Licensee was not present to assist with developing a plan of correction. The licensee shall submit an LIC500 of a current staffing schedule as well as a statement of understanding of the regulation cited. POC shall be submitted by 03/19/2026.
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delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by absence of staff on 3/18/2026. This poses a direct threat to the health and safety of 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: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20260317095423
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: 03/18/2026
NARRATIVE
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Due to absence of staffing, an immediate civil penalty of $500 was issued during todays visit.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D. Appeal rights were given. A copy of this report and appeal rights were provided to the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3