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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701251
Report Date: 06/11/2024
Date Signed: 06/11/2024 11:09:55 AM


Document Has Been Signed on 06/11/2024 11:09 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
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: 81DATE:
06/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alfredo CruzTIME COMPLETED:
11:30 AM
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On 6/11/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a follow up Pre-licensing visit. LPA met with facility staff Alfredo Cruz, who assisted with today’s inspection. Alfredo Cruz is proposed to be the new administrator when the facility license is approved. Alfredo Cruz’s administrator certificate application is currently pending. The licensee was unable to attend today's inspection.

LPA toured the facility with Alfredo Cruz. During today's visit, all corrections were completed.
- Each resident in assistant living building need to have a call pendant. (Completed)
- All heat detector censors shall be functioning. (Completed)

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. A Component III was completed at this time with Alfredo Cruz. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. Final approval of the license by the Applications Analyst is pending.

Per the California Code of Regulations, Title 22, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
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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