342700005-10-29-2025-27-AS-CACL-DN7LE7-20251107074101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700005
Report Date: 10/29/2025
Date Signed: 10/29/2025 01:53:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
03/03/2025 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20250303114503

FACILITY NAME:	REVERE COURT		FACILITY NUMBER:	342700005
ADMINISTRATOR:	IRENE CHARNELL		FACILITY TYPE:	740
ADDRESS:	7707 RUSH RIVER DRIVE		TELEPHONE:	(916) 392-3510
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	72	CENSUS: 63	DATE:	10/29/2025
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Marina Smetyukh		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1) Questionable death.
2) Staff did not ensure resident received adequate nutrition while in care.
3) Staff did not ensure adequate care and supervision was provided to resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Revere Court RCFE on 10/29/25 at 1:05pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator Marina Smetyukh and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. The department obtained and reviewed R1's death certificate which did not indicate any cause that was determined to be questionable. LPA Gould conducted interviews with nine (9) staff members. All interviews conducted did not corroborate the allegations listed inthe complaint. Per staff statements, hospice notes reviewed and staff communications and daily notes all indicated that as R1 was declining and on hospice care, as part of R1's decline R1 was reported to have had a decline in appetite and would not consume as much food as prior to being placed on hospice. Report Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

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 2

Control Number 27-AS-20250303114503

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REVERE COURT	FACILITY NUMBER: 342700005
	VISIT DATE: 10/29/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Additionally, The department has received statements by interviewed staff that R1 only had one significant fall prior to their death. Per staff statements R1 only had one fall which resulted in injury, the department received notification and documentation of fall and selected treatments that did not meet department requirements for further investigation. Staff interviewed provided statements that R1's decline and instability was addressed by increased checks and supervision and the implementation of a bed alarm that would alert staff members if/when R1 would attempt to get out of bed without staff assistance. All staff statements received were consistent with a resident on hospice and declining prior to death.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of (Questionable Death, Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2