<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701251
Report Date: 09/19/2024
Date Signed: 09/19/2024 05:20:04 PM


Document Has Been Signed on 09/19/2024 05:20 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:
10:00 AM
MET WITH:Alfredo Cruz TIME COMPLETED:
10:30 AM
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
On 09/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua was met by Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit.
Current census was 85. A brief interview with FDA Cruz and a tour of the facility was conducted.

The purpose of this visit was to follow up on an incident regarding an elopement from the facility on 09/16/2024.
On 09/17/2024, LPA Pascua received a phone call from the facility stating that R1 eloped from the facility. It was stated based on interviews of facility staff, R1 was last seen after dinner on 09/16/2024 around 9:00pm in the courtyard smoking. On 09/17/2024, facility staff checked on R1 in their bedroom where they were not found. At approximately 9:30am, staff notified the Facility Designated Administrator who stated that the facility staff conducted a perimeter search by foot. Additionally, the facility conducted a search in the surrounding areas via car and could not find R1. Staff then notified Sacramento Sheriff's office to report the missing resident.
On 09/18/2024, LPA Pascua received notification that R1 was found by Sacramento Sheriff's Department approximately 2.8 miles away from the facility. R1 was evaluated by medical personnel to check their vitals and returned back to the facility before 12:00pm. Upon return to the facility, R1 was unaware that they left the facility and repeated stated their feet hurt. Facility staff conducted additional assessments and observed that R1 was unable to walk around by themselves and needed a wheelchair to ambulate to their room and had several blisters on their feet. It was stated by staff that R1 was able to ambulate and walk around themselves and did not have blisters on their feet prior to the elopement. LPA learned that the facility called Emergency Services and R1 was assessed and treated in the Emergency room and discharged with Home Health Services.
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 3


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
VISIT DATE: 09/19/2024
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
26
27
28
29
30
31
32
LPA reviewed R1's physicians report and care plan which states that this resident has a diagnosis of dementia and was not able to leave the facility unattended with safety checks twice a day conducted by facility staff. It was stated by facility staff that safety checks are done during medication pass, incontinence care checks, however it was not clearly stated in the care plan.

In addition, LPA reviewed the facilities staffing records for 09/16/2024 and it was learned that there were 3 staff members present during graveyard shift of which 2 staff members who were hired through an outside agency. It was unclear if the staff member assigned to R1's hall conducted health and safety checks during the course of their shift.



R1's care plan also indicates that this resident needs consistent assistance due to disorientation and memory loss. An interview conducted with facility staff revealed that R1 had started showing tendencies to leave the facility to purchase additional cigarettes. Staff state that they worked with the responsible party to obtain additional cigarettes and was believed to help mitigate elopement tendencies.

Based on the information gathered, the facility did not ensure that R1 was in secured environment based on the resident's LIC602's indication that R1 could not leave the facility and additional care and supervision needs due to their disorientation and memory loss. As a result, an immediate $500.00 civil penalty shall be assessed on September 19,2024 for bodily injury and severe pain, which posed an immediate threat to the Health, Safety, and Personal Rights of R1.

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility. An exit interview was held, and a copy of the report was provided.

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
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/19/2024 05:20 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
HSC
1569.312(d)

1
2
3
4
5
6
7
1569.312(d)Basic services requirements: Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as evidence by: Based on file reviews and interviews,
1
2
3
4
5
6
7
Facility Administrator agrees to conduct elopement drill and training for all staff by POC date 09/20/2024. Facility Administrator will email LPA training logs by POC date 09/20/2024 by 5 PM.
8
9
10
11
12
13
14
 the Licensee did not ensure staff were aware of R1 general whereabouts as R1 was last seen on 09/16/2024 and was not found in their room the next morning. R1 was found outside of the facility on 09/18/2024 by Sacramento Sheriff's department and returned R1 to the facility. This posed an immediate health and safety risk to R1.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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)
Page: 3 of 3