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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920252
Report Date: 03/18/2026
Date Signed: 03/18/2026 03:34:30 PM

Document Has Been Signed on 03/18/2026 03:34 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: 1DATE:
03/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Neha SharmaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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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 the unannounced annual inspection. 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.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA and LPM reviewed resident (1) and staff (2) files. The resident file was missing a reappraisal. LPA only observed the initial appraisal which was completed upon move-in. During the staff file review, LPA observed S1 missing current CPR certification. S2 missing current first aid certification and physical.

During a medication audit, LPA and LPM observed the following: medications which were prescribed for residents who moved out in January were still at the facility. On R1's MAR, potassium chloride was crossed out to indicate it was discontinued, however there was not a discontinued order on file. LPA and LPM observed two medications which were in R1's room, not locked up and accessible to the resident.

See 809-D for citations issued during todays visit.

Exit interview conducted. A copy of this report and appeal rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Melissa Parks
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/18/2026 03:34 PM - It Cannot Be Edited


Created By: Melissa Parks On 03/18/2026 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 occuried resident rooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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Licensee was not present to assist with developing a plan of correction. The licensee shall submit training for all staff regarding the above regulation. Additionally, the Licensee will submit a plan regarding centrally storing medications.
Type A
Section Cited
CCR
87465(c)(1)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above in that there was no discontinue order on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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Licensee was not present to assist with developing a plan of correction. The licensee shall submit a discontinue order for R1's medication. Additionally, the Licensee will submit training for all staff regarding discontinued medication procedures according to the regualtion cited.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Melissa Parks
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2026 03:34 PM - It Cannot Be Edited


Created By: Melissa Parks On 03/18/2026 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Licensee was not present to assist with developing a plan of correction. The licensee shall submit CPR training for R1 by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Melissa Parks
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2026 03:34 PM - It Cannot Be Edited


Created By: Melissa Parks On 03/18/2026 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Licensee was not present to assist with developing a plan of correction. The licensee shall submit proof of physical for R2 by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Melissa Parks
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2026 03:34 PM - It Cannot Be Edited


Created By: Melissa Parks On 03/18/2026 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting a reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Licensee was not present to assist with developing a plan of correction. The licensee shall submit a reappraisal for the current resident. Additionally the licensee will submit a statement of understading regarding the regulation cited.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Melissa Parks
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2026 03:34 PM - It Cannot Be Edited


Created By: Melissa Parks On 03/18/2026 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)



This requirement is not met as evidenced by: medication belonging to previous residents (moved out in January) still being stored at the facility
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in storing previous resident medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Licensee was not present to assist with developing a plan of correction. The licensee shall return to pharmacy or destroy medications based on Title 22 regualtions. Licensee will submit documentation or destroyed/returned medications by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Melissa Parks
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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