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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700005
Report Date: 12/30/2021
Date Signed: 01/02/2022 06:10:41 PM

Document Has Been Signed on 01/02/2022 06:10 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:REVERE COURTFACILITY NUMBER:
342700005
ADMINISTRATOR:CHAPPELL, BRENDAFACILITY TYPE:
740
ADDRESS:7707 RUSH RIVER DRIVETELEPHONE:
(916) 392-3510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 72CENSUS: 70DATE:
12/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brenda ChappellTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude an investigation that began on the visit of 2/26/21. LPA met with Brenda Chappell and stated the purpose of the visit.

On 2/26/21, LPA inquired about an incident report received by Community Care Licensing (CCL) indicating that resident (R1) received medication that belonged to (R2) which indicates there was a medication error. During that visit, LPA was able to interview Staff 1 (S1) and Executive Director. S2 was interviewed on 2/27/21.

LPA requested, received and reviewed a copy of the medication record for both (R1) and (R2) and a revised Incident Report (SIR), and Medication Training documentation for S1.

S3 was interviewed today during this visit. Upon review of the training schedule, S1 received orientation, training/shadowing, and worked with 2 Medication Technicians from 2/2/21 - 3/3/21 with the exception of the days off work.

Based on interviews, and documentation the preponderance of evidence standards has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809D during this visit. If any of the cited deficiency is not corrected by the noted due dates; additional civil penalties may be assessed. The facility staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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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Document Has Been Signed on 01/02/2022 06:10 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/30/2021 at 10:42 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: REVERE COURT
FACILITY NUMBER: 342700005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2021
Section Cited
CCR
87465(c)(2)

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Incidental Medical and Dental Care
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: Once ordered by the physician the medication is given according to the physician's directions.
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Administrator shall provide additional training to S1 regarding medication management.

POC cleared prior to todays visit.
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This requirement is not met as evidenced by: Staff administered the incorrect medication to R1 that belonged to R2.
Based on interviews Licensee did not ensure prescribed medication(s) were administered to R1 as prescribed. This posed 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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2021


LIC809 (FAS) - (06/04)
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