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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701251
Report Date: 05/30/2024
Date Signed: 05/30/2024 04:40:10 PM


Document Has Been Signed on 05/30/2024 04:40 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 RIDGE ASSISTED LIVING, LLCFACILITY NUMBER:
342701251
ADMINISTRATOR:KHODORKOVSKY, AARONFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:94CENSUS: 77DATE:
05/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aaron KhodorkovskyTIME COMPLETED:
02:00 PM
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On 5/30/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing Inspection. LPA met with facility representative/Administrator Aaron Khodorkovsky and explained the purpose of the visit. Administrator Aaron Khodorkovsky and staff Alfredo Cruz assisted with today’s visit.

It was learned that this facility will be licensed to serve up to (94) non-ambulatory residents. Facility has two buildings, one for assistant living and one for memory care. All bedrooms are double occupancy and were approved for non-ambulatory or bedridden. Hospice granted for 20 residents. LPA toured and inspected the physical plant inside and outside with the administrator Aaron Khodorkovsky and staff Alfredo Cruz to ensure there were no health and safety concerns on 05/30/2024 at 9:30 AM. There were (77) residents in care at this time.

LPA observed the lobby area and common areas were clean and furnished. In addition, resident rooms, kitchen, dining area, laundry room and activity room was toured. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 108*F during this visit which was within the required range of 105-120*F. The temperature inside the facility measured at 72*F which was within the required range of 68-85*F. LPA observed fire extinguisher(s) and central heating and air in the facility were up to date and in good repair. LPA observed no obstruction of emergency exits inside or outside of facility.

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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 RIDGE ASSISTED LIVING, LLC
FACILITY NUMBER: 342701251
VISIT DATE: 05/30/2024
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LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time.

During today's visit, there were a few items that need corrected. The following items that need to be corrected were as follows:
- Each resident in assistant living building need to have a call pendant.
- All heat detector censors shall be functioning.

Based on a review of this facility during this Prelicensing visit, it was determined that this facility has not passed the pre-licensing component of the application process at this time. The Department will return at a later date to complete the pre-licensing. The applicant will correct outstanding issues and inform LPA Truong when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
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