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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005531
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:23:38 PM


Document Has Been Signed on 04/04/2023 12:23 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
317005531
ADMINISTRATOR:ILONA CORPUSFACILITY TYPE:
740
ADDRESS:3265 BLUE OAKS DRTELEPHONE:
(530) 887-8600
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: DATE:
04/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ilona CorpusTIME COMPLETED:
12:30 PM
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On 4/4/2023 LPA Tryon visited the facility to do a case management visit regarding resident R1. R1 has had some difficulty with another resident and with a family member in the past couple of weeks (separate incidents).
LPA met with Executive Director Ilona Corpus. The first incident involved another resident who got into R1's space and upset R1, causing a reaction.

The second incident involved an issue with a family member. The facility had reported the incident appropriately to police, APS/Ombudsman, to CCL and to doctor.

In reviewing video tapes of the visit between R1 and family member, the authorities determined that the family member did nothing wrong or aggressive.

The facility has made a plan with the family to visit in common areas, staff keep an eye on the situation, and family is to ask staff for assistance if needed. Staff are checking on R1 hourly and charting. Medications have also been reviewed To date, this plan is going well.

At this time, it appears that the facility staff reacted quickly, reported situations appropriately, reviewed medications/medical issues, and made and is following an appropriate plan.

No deficiencies were cited at this visit. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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