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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701251
Report Date: 08/29/2024
Date Signed: 08/29/2024 02:15:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2024 and conducted by Evaluator Holly Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240823155140
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: 84DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Alfredo CruzTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility did not pass fire inspection clearance.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open this complaint investigation. LPAs Moleski and Williams met with Administrator Alfredo Cruz and explained the purpose of the visit.

LPAs Moleski and Williams obtained a fire inspection report for Apple Ridge from Cruz dated 8/22/24. LPAs Williams and Moleski reviewed the inspection report and observed many violations including, but not limited to, many fire doors which need repairs, latches, and smoke seals, and permits for change of use of a resident room. According the fire inspection report, resident room 41 was converted into a administrative office without proper permitting. LPAs Moleski and Williams reviewed a facility sketch which shows the current administrative office labeled as room number 41. LPAs Moleski and Williams were not notified regarding this change of use. In an interview, the fire inspector who authored the report said that this facility's previous fire clearance was granted in error due to these multiple violations which were not previously observed. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240823155140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/29/2024
NARRATIVE
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In an interview, Cruz admitted that this facility had not passed its most recent fire inspection, as described in the fire department's report. The report states that corrections must be made prior to a reinspection on or around 9/19/24.

The department has determined the following as it relates to the allegation that this facility did not pass its fire inspection clearance:

Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 87202(a). Civil penalties in the amount of $500 were assessed due to a fire clearance violation. An exit interview was held with Cruz. Appeal rights and a copy of this report were left with Cruz.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240823155140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2024
Section Cited
CCR
87202(a)
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"(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal." This requirement was not met as evidenced by:
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Licensee agrees to submit to CCLD a written plan outlining repairs to be made, including a timeline for reinspection, by POC due date. holly.williams@dss.ca.gov

Licensee agrees to request a new STD 850 fire clearance after repairs have been made.
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Based on interviews and record review, this facility did not adhere to local fire requirements and is currently in violation of its previously issued fire clearance, which poses an immediate health, safety and/or personal rights risk.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
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