347003117-2-22-2023-27-AS-AMAZ-CPATHZ-20230222134531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 02/21/2023
Date Signed: 02/22/2023 01:45:41 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/22/2023 01:45 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 LIVING		FACILITY NUMBER:	347003117
ADMINISTRATOR:	MICHELLE HARDY		FACILITY TYPE:	740
ADDRESS:	3950 ANNADALE LANE		TELEPHONE:	(916) 489-6900
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	82	CENSUS: 63	DATE:	02/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	03:30 PM

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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee made an unannounced visit to this facility to conduct an annual inspection on 02/21/2023 at 11:35 AM. LPAs met with Ashley Sylve and stated the purpose of today’s visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires on March 24, 2023. The facility is licensed for 82 residents, which 58 can be non-ambulatory and 12 can be bedridden and in the memory care building there can be 12 bedridden. The facility has a hospice waiver for 6 residents. There are currently 63 residents who reside at this facility.

LPAs toured the facility with the administrator on 02/21/2023.

The facility has implemented Covid-19 precautionary measures, and has a supply of PPE. The facility has hand sanitizer throughout the facility. During today's annual visit, the facility was sanitary and clean. In addition, the facility has an activities calendar posted, and an entertainer was present during the facility visit. The facility also has a food menu. LPAs toured the facility Kitchen, and it was sanitary and clean. The facility has an adequate food supply. The facility has a Nutritionist, and last audit was last year. Facility Ansal and stove hood sprinkler were last inspected August 8, 2022. In addition, the facility has an ECOLAB water temp log. The facility has one chef and three kitchen staff, and on-boarding a kitchen staff. The facility water temperature measured at 105 degrees, and the facility temperature measured at 71 degrees. LPA Martinez reviewed five staff files and five resident files. The facility files were up to date.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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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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
	VISIT DATE: 02/21/2023

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Resident rooms are clean and furnished. Not all Residents' bathrooms located in their bedrooms are wheelchair accessible. Some residents are not able to access their bathroom due to their wheelchair type and size. In addition, The facility call system is not in good repair and some call buttons have not been replaced. However, the facility is currently working on repairing call system and repairing wheelchair accessibility issue in resident bathrooms.

Facility Documents Requested by 2/27/23 5PM.

Liability Insurance.

Facility Sketch
Plan of Operation
Last STD 850 Fire inspection

As a result of this visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview conducted and 809, 809D, and appeals right given to administrator at the end of visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/22/2023 01:45 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: 02/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 02/22/2023 Section Cited CCR 87303(1)(1)	1 2 3 4 5 6 7	Maintenance and Operation 87303(1)(1):Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal...	1 2 3 4 5 6 7	The Administrator agrees to email LPA Martinez a repair plan by POC date 02/22/2023 5PM. The Administrator provide bi-weekly updates until signal system is repaired.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on observation, interview the facility singal systmen is not in good repair. The facility Administrator reported the facility is currently working replacing signal system.This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type A 02/28/2023 Section Cited CCR87307(a)(d)(1)	1 2 3 4 5 6 7	Personal Accommodations and Services: 87307(a)(d)(1)...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents...following space and safety provisions shall apply to all facilities...Sufficient room shall be	1 2 3 4 5 6 7	The Administrator agrees to email LPA Martinez a wheelchair accessibility repair plan by POC date 02/22/2023 5PM. The Administrator agrees to provide bi-weekly updates until wheelchair accessibility issue is cleared.
	8 9 10 11 12 13 14	available to accommodate persons served in comfort and safety...Based on observation and interviews not all wheelchairs are accessible in residents' bathrooms, which are located in their rooms. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC809 (FAS) - (06/04)

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