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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701251
Report Date: 09/19/2024
Date Signed: 09/19/2024 05:19:24 PM


Document Has Been Signed on 09/19/2024 05:19 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:CRUZ, ALFREDOFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:94CENSUS: 85DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alfredo Cruz TIME COMPLETED:
10:00 AM
NARRATIVE
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On 09/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA was met with Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit.

Current census was 85. A tour of the facility was conducted and a brief interview with FDR Cruz was conducted.

The purpose of this visit was to follow up on 22 incident reports that were received by the department via Fax on from 08/18/2024 to 08/19/2024.

Of the 22 incident reports, the facility reported 5 COVID positive residents and 17 incident reports regarding various medical conditions. These incidents reported occurred between the dates of 07/26/2024-07/31/2024 and 08/02/2024-08/08/202/24. All incident reports were reported to the department and time stamped on the dates of 08/18/2024 or 08/19/2024 via fax.

Based on the information above, the facility did not report these incidents to the department within the seven days of occurrence. The following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, appeals rights and a copy of the report was given end the of this visit.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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 2


Document Has Been Signed on 09/19/2024 05:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
87211(a)(1)

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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This is not met as evidenced by:
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Licensee to send an acknowledgement of understanding letter regarding 87211 by POC due date of 09/20/2024. Licensee to conduct in-service training on Reporting Requirements and send proof of training by 09/27/2024.
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Based on observation and record review, the licensee did not ensure that the facility reported 22 incident reports within seven days of occurrence. LPA reviewed incident reports received by the department on 08/18/2024 and 08/19/2024 and found that the incidents occurred between the dates of 07/26/2024-07/31/2024 or 08/02/2024-08/08/2024 and were reported outside of the seven-day required period. This poses an immediate health, safety and personal rights risks to persons in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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