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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700889
Report Date: 11/20/2025
Date Signed: 11/20/2025 12:06:22 PM

Document Has Been Signed on 11/20/2025 12:06 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:APPLE RANCH HOMEFACILITY NUMBER:
342700889
ADMINISTRATOR/
DIRECTOR:		AARON KHODORKOVSKYFACILITY TYPE:
735
ADDRESS:2317 PECAN GROVE WAYTELEPHONE:
(916) 693-5088
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 3CENSUS: 3DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Flordeliza NavarroTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 11/20/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to complete the annual inspection. 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 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.
This LPA observed that the Designated Facility Administrator's Certificate # 7016947735 expires on 08/19/2026.  Document Link Icon
LPA observed that the fire extinguisher was last inspected on 08/26/25 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 111.6 degrees and was in compliance at the time of inspection. LPA observed soap and towels along with trash cans with lids in the two bathrooms.

This LPA then went on to inspect the 3 residents' bedrooms. Each of the client's 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.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/20/2025
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LPA observed that all windows, window screens, and gutters were in good condition and were not in need of repair.

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 2 staff files and 2 resident files. All were in compliance at the time of inspection. LPA requested an updated LIC 602 for 1 resident (R1) as it pertained to ambulatory status.
LPA verified that all employees listed on the LIC 500 were background cleared.
 
LPA requested the following documents be emailed to CCLASCPSacramentoSouthRO@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, signed and dated 2025
LIC 402: Surety Bond, if applicable
LIC 610E: Emergency Disaster Plan, signed and dated 2025
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.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
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