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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701251
Report Date: 10/17/2025
Date Signed: 10/17/2025 03:36:21 PM

Document Has Been Signed on 10/17/2025 03:36 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/
DIRECTOR:		ILONA CORPUSFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 94CENSUS: 82DATE:
10/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:26 PM
MET WITH:Ilona CorpusTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit on October 17, 2025. LPA Lee met with Executive Director Ilona Corpus and explained the purpose of the visit. The census is 82

Today's visit was conducted to follow up on a LIC 624 Incident Report received by the Department on October 4, 2025, concerning an Absence Without Leave (AWOL) incident that occurred on October 4, 2025. The report indicates that at 7:20 AM during room checks staff alerted Med-tech that resident 1 (R1) was not in R1’s room. A search of the community and surrendering area was immediately conducted. R1 then was located approximately four blocks from the building on the ground. According to R1’s LIC 602 Physician’s Report, dated November 18, 2024, R1 is diagnosed with dementia and is not able to leave the facility unassisted. Based on today's case management visit, The following deficiency was identified and cited in accordance with the California Code of Regulations, Title 22, and the California Health and Safety Code. An immediate civil penalty was accessed today, for an immediate health and safety and a repeat violation in the amount of $1000 since this violation was also cited on 07/29/2025. The deficiency can be found on the LIC 809-D page. An exit interview was conducted, and a copy of the LIC 809 report, LIC 809-D page, LIC 421IMsand appeal rights were given to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/17/2025 03:36 PM - It Cannot Be Edited


Created By: Pang Lee On 10/17/2025 at 02:47 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: APPLE RIDGE ASSISTED LIVING, LLC
FACILITY NUMBER: 342701251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2025
Section Cited
CCR
1569.312(a)

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1569.312(a) Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
This requirement is not met as evidence by:
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The Licensee/Administrator stated that she has conduct an in-service training from an outside agency with facility staff to go AWOL and basic services. Administrator stated that she will conduct another training course on preventing AWOL and that she shall send the in-service training materials, and a signature sheet of all staff who attended the in-service. The Administrator also stated that same day of the incident a door alarm was
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Based on records review and interviews with the facility staff, the facility did not comply with the section cited above. R1 left the facility unsupervised and then was located approximately four blocks from the building on the ground. The LIC 602 states R1 was not allowed to leave the facility unassisted. This results in an immediate health and safety risk for the residents in care.
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installed that she reviewed all residents LIC 602 and wander guard was ordered for all residents whose LIC 602 states that residents have dementia and cannot leave the facility unassisted. Administrator stated that 24/7 staff will be up in the front desk at all times. Training, statement of acknowledgement and receipt of purchase of wander guards will be provided to be provided to LPA Lee by POC 10/24/2025 end of day 5:00 PM

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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2025


LIC809 (FAS) - (06/04)
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