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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700889
Report Date: 10/20/2021
Date Signed: 10/20/2021 10:03:39 AM

Document Has Been Signed on 10/20/2021 10:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
10/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Flordeliza Navarro TIME COMPLETED:
10:30 AM
NARRATIVE
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On 10/20/21 at 9:15am Licensing Program Analysts (LPA) Kevin Gould arrived at Apple Ranch Home to conduct a case management inspection to address an incident that took place between R1 and S1 (see confidential names list, LIC-811 dated 10/20/21). On 10/13/21 S1 was communicating with R1 and made physical contact with R1 to encourage R1 to look S1 in the eyes to make sure the communication was understood. S1 admitted to the error and personal rights violation and stated that there was no malice or negative intentions and R1 understands that the action was not appropriate.

Based on the documented report and conversations with S1 the following deficiency is cited per California Code of Regulations, TITLE 22.

An exit interview was conducted and appeal rights 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: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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Document Has Been Signed on 10/20/2021 10:03 AM - It Cannot Be Edited


Created By: Kevin Gould On 10/20/2021 at 09:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: APPLE RANCH HOME
FACILITY NUMBER: 342700889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited
CCR
80072(a)(1)

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Personal Rights: Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by incident report dated 10/14/21 and
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Administrator will contact Regional Center coordinator to arrange for personal rights training to be conducted by the regional center. Administrator will send LPA confirmation of contact with regional center and will submit her training certificate from the regional center to clear the deficiency.
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statements obtained from S1 which poses a potential health, safety or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
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