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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 01/31/2021
Date Signed: 01/31/2021 06:02:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:APPLE RIDGE ASSISTED LIVINGFACILITY NUMBER:
347003117
ADMINISTRATOR:MICHELLE HARDYFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:82CENSUS: 30DATE:
01/31/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Michelle Hardy, Administrator TIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada contacted the facility via phone to issue a deficiency found during the course of a complaint investigation. Facility was contacted via phone due to current Covid-19 precautionary measures in place. LPA spoke to Administrator, Michelle Hardy, and explained purpose of today's phone call.

During the complaint investigation, it was discovered that facility did not make resident's (R1) family member/responsible person aware when resident was observed to have bruising on her left side, including a mass/bump on her left breast. Resident was receiving assistance with all activities of daily living, including toileting and bathing and it was documented by staff on 12/24/2019 and on 12/26/2019 that resident had bruising on her inside left arm and on 12/28/2019 that resident had a big bruise on the outside of her left arm and on her left breast. Family member/responsible person was not aware of the large bruise on resident's left arm and mass/bump on resident's left breast until 12/30/2019, when they observed in person.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited.
Failure to correct the deficiency by the noted due date may result in a penalty being assessed.

Exit interview. Copy of report and appeal rights e-mailed to Administrator following exit interview. Administrator agrees to return a signed copy of the report by end of day, 1/31/2021.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2021
Section Cited

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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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Based on staff interviews and interview with resident"s (R1's) family member, the Licensee did not ensure that resident's family member/responsible person was notified of resident's bruising on resident's left arm/side and mass/bump on resident's left breast, documented in resident's file from 12/24/2019- 12/28/2019, which posed a potential risk to resident 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: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2021
LIC809 (FAS) - (06/04)
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