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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701251
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:28:29 PM


Document Has Been Signed on 08/22/2024 02:28 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: 85DATE:
08/22/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lisa JohansenTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit to the facility on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. LPA Valerio met with Business Office Manger (BOM) Lisa Johansen and explained the purpose of today's visit. Staff (S-1) excluded as a result not related to this facility.

LPA Valerio handed the Order to Licensee/Facility of Immediate Exclusion From Facility letter to Lisa Johansen and explained that staff, if present, needed to leave the facility immediately. S1 is to be removed from all shifts and removed from tonight's schedule.

An exit interview was held with BOM Lisa, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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