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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700889
Report Date: 12/22/2021
Date Signed: 12/22/2021 10:38:12 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2021 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211202142457
FACILITY NAME:APPLE RANCH HOMEFACILITY NUMBER:
342700889
ADMINISTRATOR:NAVARRO, FLORDELIZAFACILITY TYPE:
735
ADDRESS:2317 PECAN GROVE WAYTELEPHONE:
(916) 693-5088
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:3CENSUS: 3DATE:
12/22/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Flordeliza NavarroTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Medication: Resident forced to take medications by restraint
Food Service: Resident not receiving adequate food for meals
Personal Rights: Resident is not being accorded dignity in his/her personal relationships with staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Apple Ranch Home on 12/22/21 at 9:30am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because Client #1 (see confidential name list LIC-811 dated 12/22/21) provided LPA with inconsistent statements regarding the alleged incident on 12/2/21. LPA conducted interviews with staff present at the time of the alleged incident and all staff interviewed denied the allegations. LPA conducted a phone interview with RP who informed LPA Client #1 has a history of making false allegations. LPA spoke with Regional Center for Client #1 who informed LPA that a team member conducted a visit at the home and had no concerns at the time of visit and also received inconsistent statements regarding the alleged incident. Client #1's statements would change when asked by Regional Center staff.

Report Continued on LIC 9099-C. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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-20211202142457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: APPLE RANCH HOME
FACILITY NUMBER: 342700889
VISIT DATE: 12/22/2021
NARRATIVE
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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 Medications, Food Service and Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22

Exit interview was conducted with the facility administrator. 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: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2