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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 08/29/2023
Date Signed: 08/29/2023 01:29:59 PM


Document Has Been Signed on 08/29/2023 01:29 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:APPLE RIDGE ASSISTED LIVINGFACILITY NUMBER:
347003117
ADMINISTRATOR:ASHLEY SYLVEFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:82CENSUS: 62DATE:
08/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Aaron KhodorkovskyTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Avelina Martinez and IB Investigator Juan Barajas arrived at facility unannounced to conduct a case management visit on 08/29/2023 at 9:00 AM. LPA Martinez and IB Investigator Juan Barajas met with Aaron Aaron Khodorkovsky and explained the purpose of the visit.

The purpose of the visit today is in response to an administrator change. LPA Martinez requested the following Administrator documents:
  • Cover Letter or LIC 200 Form Licensee requesting administrator change
  • LIC 308 Designation of Facility Responsibility
  • LIC 503 Health Screening Report
  • LIC 500 Personnel Report
  • Administrator Certificate
  • LIC 501 Personal Record
  • LIC 508 Criminal Record Statement

The requested documents will be emailed to Licensing Program Analyst Avelina Martinez by 08/31/2023 5:00 PM.

Furthermore, It was learned Aaron Khodorkovsky will be the assigned Administrator until a permanent Administrator has been assigned to the facility.

There were no deficiencies cited at this visit, and an exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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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