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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 09/15/2023
Date Signed: 09/15/2023 12:55:10 PM


Document Has Been Signed on 09/15/2023 12:55 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: 64DATE:
09/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer Siegel and Brittnay RaganTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 09/15/2023 at 9:30 AM to conduct a case management visit. LPA Martinez met with Jennifer Siegel and Brittnay Ragan and explained the purpose of the visit.

The purpose of the visit is to follow up on a learned deficiency during complaint investigation 27-AS-20230808125706. LPA Martinez reviewed R1's LIC 601 Identification and Emergency Information form, and it states to contact witness 1 (W1) in case of emergency. Throughout the investigation, It was learned resident 1's (R1) emergency representative contact (W1) was not informed of emergency hospitalization incidents. The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted, and a copy of this report, 809-D page, and appeals rights 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: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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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Document Has Been Signed on 09/15/2023 12:55 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
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: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87468.1(a)(8)

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87468.1(a)(8) Personal Rights of Residents in All Facilities: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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Facility staff agrees to conduct in-service training on reporting and reviewing the LIC 601 Identification and Emergency Information form with all staff by poc date 09/29/2023. LPA Martinez will clear POC by facility visit.
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This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure R1's emergency representative contact (W1) was informed of emergency incidents that required hospitalization. This posed a potential health and safety risk to R1.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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