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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 05:19:36 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:
02:00 PM
MET WITH:Alfredo Cruz TIME COMPLETED:
03:00 PM
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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 FDA Cruz was conducted.

The purpose of this visit was to follow up on an incident report that was received by the department on 09/17/2024. The incident report states that on 09/14/2024, R1 reported that they had a severe headache and requested for their prescribed medication of Oxytocin, however staff advised that this resident was out of this PRN medication. Subsequently, R1 requested to be sent out via Emergency Services for further evaluation.

During the course of this visit, LPA obtained R1's medication administration record, physicians orders, and narcotic log.

Due to insufficient time to review documentation, the department will follow up at a later time to complete this case management visit.

No deficiencies during the course of this visit.

An exit interview was conducted, 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)
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