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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 09/15/2023
Date Signed: 09/15/2023 12:56:04 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230808125706
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: 63DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer Siegel and Brittnay RaganTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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9
Facility did not notify resident's responsible party of resident's hospitalization.
INVESTIGATION FINDINGS:
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On 09/15/2023 at 9:30 am, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Jennifer Siegel and Brittnay Ragan during today’s visit and explained the purpose of today’s visit.

Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility documents. LPA Martinez reviewed resident 1's (R1) facility file. LPA Martinez reviewed R1's Admission Agreement, LIC 602 Health Certification Form, LIC 603 Preplacement Appraisal Information form, and LIC 601 Identification and Emergency Information form and all of the documentation indicates R1 did not have a responsible party. Furthermore, R1 signed all facility documentation as they were their own responsible party. As a result, R1 did not have a responsible party, therefore the allegation is unfounded. However, R1 had an emergency contact, and it was learned the emergency contact was not informed of emergency 911 calls, which resulted in hospitalization. See Case Management for deficiency. Continued...
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20230808125706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/15/2023
NARRATIVE
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This agency has investigated the complaint alleging (Facility did not notify resident's responsible party of resident's hospitalization). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. 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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230808125706

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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer Siegel and Brittnay RaganTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility illegally evicted resident.
Facility is withholding resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 09/15/2023 at 9:30 AM to deliver complaint findings, LPA Martinez met with Jennifer Siegel and Britnay Ragan and explained the purpose of the visit.

Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility documents. LPA Martinez reviewed resident 1's (R1) facility file. It was learned R1 was sent to the Emergency room on July 04, 2023 and was discharged to another facility. R1 arrived at Apple Ridge Assisted Living facility on July 19th, 2023, and they signed out their belongings at 3:30 PM. Moreover, it is unknown where R1's belongings are located at since R1 signed out their belongings from Apple Ridge Assisted Living Facility. Therefore, there is not enough evidence to prove the facility withheld R1's belongings.

Continued...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230808125706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/15/2023
NARRATIVE
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Moreover, R1 returned to the facility on July 21, 2023, and R1 was sent out to the Emergency Room, and R1 did not return to Apple Ridge Assisted Living facility. As a result, there is not enough evidence to prove R1 was illegally evicted from Apple Ridge Assisted Living facility.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.


An exit interview was conducted, and a copy of the 9099 report and LIC 9099-D were given 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5