<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342701251
Report Date:
09/03/2024
Date Signed:
09/03/2024 03:39:17 PM
Document Has Been Signed on
09/03/2024 03:39 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, LLC
FACILITY NUMBER:
342701251
ADMINISTRATOR:
KHODORKOVSKY, AARON
FACILITY TYPE:
740
ADDRESS:
3950 ANNADALE LANE
TELEPHONE:
(916) 489-6900
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95821
CAPACITY:
94
CENSUS:
84
DATE:
09/03/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:50 PM
MET WITH:
Alfredo Cruz
TIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski arrived unannounced to Apple Ridge Assisted Living. LPAs Williams and Moleski met with Alfredo Cruz the facility administrator and explained the purpose of the visit.
LPAs Williams and Moleski reviewed a facility sketch which was submitted to the Community Care Licensing Division (CCLD) during this facility's change in ownership. A temporary designation was approved for room #41. Cruz has informed LPAs Williams and Moleski that Cruz plans to have his office in #41 temporarily. Cruz agreed to notify licensing when there is a permanent change in use to room #41. Cruz said he would provide LPA Williams an estimated timeline regarding the future use of the room and the permanent placement of the administrator's office.
No deficiencies were cited during this visit. Technical assistance was provided regarding notifications of change of use of rooms or buildings. An exit interview was held and a copy of this report was left with Cruz.
SUPERVISOR'S NAME:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR NAME:
Holly Williams
TELEPHONE:
916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE:
09/03/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/03/2024
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
1