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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005531
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:17:01 PM


Document Has Been Signed on 12/07/2023 12:17 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: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:
12/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer FustonTIME COMPLETED:
12:30 PM
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On 12/7/2023 LPA Tryon visited the facility to follow up on an incident report received by CCL. Resident R1 had fallen in his room and injured his head and received a fracture; and was hospitalized.

LPA was following up to find out how R1 is doing, prevention measures in place, etc.
LPA learned that R1 has returned to the facility and is doing okay. He has apparently returned to "baseline" and is generally "himself" at this time. His physician has recommended some treatments to strengthen him. The facility had fall prevention measures in place already including a fall alarm in his room. Unfortunately, when the alarm sounds the person has already fallen.

The facility will begin participation in a new program next week that includes recording a record of a fall, which will allow staff to study the occurrence to see if anything can be done to prevent/mitigate future falls.

The responsible parties are on board with the plan.

The facility appears to be taking appropriate measures on behalf of the resident at this time.

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: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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