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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700889
Report Date: 11/19/2024
Date Signed: 11/19/2024 10:55:54 AM

Document Has Been Signed on 11/19/2024 10:55 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:APPLE RANCH HOMEFACILITY NUMBER:
342700889
ADMINISTRATOR/
DIRECTOR:		NAVARRO, FLORDELIZAFACILITY TYPE:
735
ADDRESS:2317 PECAN GROVE WAYTELEPHONE:
(916) 693-5088
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 3CENSUS: 3DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Flordeliza NavarroTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 11/19/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to complete an annual inspection.  This LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator, Flordeliza Navarro. A brief interview followed.

The Designated Facility Administrator (Certificate # 6049366735 expired on 08/19/24) produced documentation that showed she has submitted her recertification materials and her application is pending.

The inspection began in the kitchen.  This LPA reviewed all the food items in the refrigerator, freezer and cabinets. LPA observed a 7-day supply of non-perishable and 2-day supply of perishable food items.  All foods were dated and stored appropriately.  LPA inspected a sample of packaged goods to verify that none were expired.  All knives and sharps were locked and inaccessible to the clients who resided in the home.

LPA observed that the fire extinguisher was last inspected on 08/15/24 by Sentinel Fire Equipment Co.

LPA tested the hot water in the bathroom closest to the kitchen to ensure it was between 105 and 120 degrees Fahrenheit.  The hot water measured 113.2 degrees and was in compliance at the time of inspection. LPA observed soap and paper towels along with trash cans with lids in the two bathrooms.

This LPA then went on to inspect the residents' bedrooms.  Each of the 3 client bedrooms had the required furniture, furnishings and lighting to be in compliance at the time of this inspection. LPA also viewed the staff room which was located off the kitchen area.

This LPA conducted an examination of the exterior of the building.  There were no bodies of water present and the yard was completely fenced in.  There was a designated area with furniture for residents to enjoy.  LPA observed that all windows, window screens, and gutters were in good condition and were not in need of repair. 
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: APPLE RANCH HOME
FACILITY NUMBER: 342700889
VISIT DATE: 11/19/2024
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Client medications were stored in a locked cabinet off the living room area and inaccessible to clients.  LPA proceeded to review the clients' medications, medication logs, and reviewed the administration of medications including PRNs with the Administrator.  LPA then went on to inspect the first aid kit to ensure that it contained all of the required materials.

This LPA then conducted a file review of 3 staff files and 2 resident files. All were in compliance at the time of inspection. LPA verified that all employees listed on the LIC 500 were background cleared.

LPA requested the following documents be emailed to CCLASCPSacramentoRO@dss.ca.gov with a copy to kimberly.viarella@dss.ca.gov.
  • LIC 500: Personnel Report; please update and remove any staff no longer employed and include all new hires in Guardian. To associate someone to your facility, submit your fingerprint transfer to sacasctransferrequest@dss.ca.gov
  • A copy of your Resident/Client Roster
  • LIC 308: Designation of Administrative Responsibility
  • LIC 402: Surety Bond, if applicable
  • LIC 610E: Emergency Disaster Plan
  • Copy of Liability Insurance
  • An updated Facility Sketch

According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.

A copy of this report was provided and an exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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