342701251-6-5-2025-27-AS-CACL-DJWSU5-20250725141035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701251
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:27:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2025 and conducted by Evaluator Holly Williams

COMPLAINT CONTROL NUMBER: 27-AS-20250108121017

FACILITY NAME:	APPLE RIDGE ASSISTED LIVING, LLC		FACILITY NUMBER:	342701251
ADMINISTRATOR:	CRUZ, ALFREDO		FACILITY TYPE:	740
ADDRESS:	3950 ANNADALE LANE		TELEPHONE:	(916) 489-6900
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	94	CENSUS: 83	DATE:	06/05/2025
		UNANNOUNCED	TIME BEGAN:	03:42 PM
MET WITH:	Brandon Collins		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are mismanaging resident's medication
Staff are falsifying resident's medication administration record
Staff used chemicals in an unsafe manner, resulting in injury to resident

INVESTIGATION FINDINGS:

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On 6/05/2025, Licensing Program Analysts (LPAs) Holly Williams and Charlie Yang arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA) Brandon Collins
Current Census was 83. A brief interview with the FDA was conducted.

Staff are mismanaging residents’ medication:

During the course of the investigation, LPA Williams reviewed facility documents and conducted interviews of nine staff members and five residents. In addition, LPA reviewed the Medication Administration Record (MAR), PRN notes, exception records and the Controlled Substance Medication Record (CSMR). LPA observed that on 11/27/2024, the Controlled Substance Medication Record (CSMR) for R6 states

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250108121017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 RIDGE ASSISTED LIVING, LLC	FACILITY NUMBER: 342701251
	VISIT DATE: 06/05/2025

NARRATIVE

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medication was given. However, the actual MAR does not show the medication was given. According to the PRN log the medication was not given and the exception log states R1 was out of the facility. LPA Williams asked S6 why would it show that the medication was given in the narcotics log and not in the MAR? S6 stated, “I do not know.” LPA Williams asked S8 why would it be documented in the CSMR and not in the MAR? S8 stated, “Then it was done in error.” S1 stated that they do not know why there would be a medication logged in the CSMR and that could not be done in error while the exception log stating out of the facility and the MAR not initialed at all. In an interview, LPA Charlie Yang learned from S6 that the last audit that they had at the facility was in the month of 1/2025. LPA Charlie Yang asked S6 if there were going to be holes in the MARS, and they stated that they could not confirm if there are going to be holes in the MARS, meaning places the medication was skipped or not given to the resident. S6 stated that they don’t have the training or the time to conduct a proper audit. When LPA Charlie Yang reviewed the MARS of R6 for the day of 4/3/2025 on 4/19/2025 the AM and the PM were missing three times, and the medication was given 1 to 2 hours earlier than it was prescribed. LPA has requested R6’s CSMR from S5 for the time of 11/1/2024 to 11/21/2024 3 times and the facility has not been able to find it. LPA asked S5 why the logs were missing and S5 said they could not find them but then said the resident R6 did not take any narcotics during that time. During review, the exception log and the PRN log, which is part of the MAR, all entries between 11/15/2024 to 11/21/2025 were missing and same with the exception log. All the other dates and times were there with a notation, and it said out of facility, but these dates are just missing. This allegation is substantiated
Staff are falsifying resident's medication administration record:
During the course of this investigation, LPA conducted record review, interviews with staff members, and residents. LPA conducted a record review of the facility’s Medication Administration Record (MAR) and Controlled Substance Medication Record (CSMR) for the dates between 11/24/2024-11/27/2024 for R6. Based on the record review conducted it was learned that S1 had initialed the Controlled Substance Medication Record on 11/27/2024 at 1:29am for R6’s medication to reflect administration and narcotic count. However, a review of the MAR shows that there were no initials for the date of 11/27/2024 for this medication. In addition, a review of the facilities exception log shows that R6 was out of the facility from 11/24/2024 at 10:58 AM to 11/27/2024 at 7:24pm. It was learned during an interview with S7, that S7 witnessed S6 drop the medication on the floor, throw it away in the trash bin, then initial the MAR to reflect that it was administered. S7 stated that they have witnessed S6 state that they are too busy and write in the MAR that the resident received their medication. 1 out of 5 staff members stated they have witnessed falsifying of the MAR by staff. Based on the information gathered, the facility staff are falsifying resident’s MARS.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250108121017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 RIDGE ASSISTED LIVING, LLC	FACILITY NUMBER: 342701251
	VISIT DATE: 06/05/2025

NARRATIVE

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Staff used chemicals in an unsafe manner:

During the course of the investigation, LPA conducted interviews with nine staff members and five residents.
Based on interviews conducted S4 stated said they try their best to make sure the resident is not in the shower but sometimes they don’t have time, and staff just spray the shower with bleach while the resident is in the shower room. S3 stated that the bleach spray runs out, and instead of getting the bleach out of the locked cabinet, they leave it in the shower to make it easier to fill the spray bottle up. Two out of the four staff members interviewed stated that there was bleach in the shower accessible to residents. According to an interview with S5 and R6, R6 did go to the hospital because of eye irritation from the bleach being sprayed in the shower while R6 was in the shower room and received medication on 4/13/2025. LPA Williams observed in the shower room, written on an empty spray bottle stating, “bleach” and “do not leave in the shower room”. This allegation is substantiated

As a result, the above allegation has been deemed to be SUBSTANTIATED. A finding that the complaint allegation was substantiated meant that the allegation was valid because the preponderance of evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed, and a copy was given to the FDA at this time.

Exit Interview

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

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