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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 09/18/2023
Date Signed: 10/03/2023 03:06:06 PM


Document Has Been Signed on 10/03/2023 03:06 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
SACRAMENTO SOUTH ASC, 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:
09/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brittany RaganTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 09/18/2023 at 10:30 AM to conduct a case management visit. LPA Martinez met with Brittany Ragan and explained the purpose of the visit.

The purpose of the visit is to follow up on learned deficiencies during a complaint investigation 27-AS-20230131143919. The following deficiencies are in regards to: administrator qualifications and pre-admission appraisal; and reassessments. It was learned resident 1 (R1) was discharged from a skilled nursing facility (SNF) and admitted into Apple Ridge Assisted Living facility on January 05, 2023. A dated December 19, 2023, medical discharging planning note reported Apple Ridge assisted Living facility agreed to accept R1, and staff would assist with establishing a primary care physician (PCP) due to the fact R1 no longer was affiliated with their prior PCP.

Throughout the investigation it was learned R1 never was provided a PCP during their stay at Apple Ridge Assisted Living facility from the period of January 05, 2023, thru January 29, 2023. Furthermore, the Administrator reported it was R1's responsibility to find their own PCP and not Apple Ridge Assisted Living facility despite R1's discharging planning note reported the facility would assist R1 with establishing a PCP. As a result, the facility did not provide assistance in arranging medical care appropriate to the conditions of R1's needs.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
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: 09/18/2023
NARRATIVE
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It was also learned the facility did not conduct proper assessments and did not conduct reassessments. Prior to R1 moving into the facility, the facility did not conduct a skin assessment, and the facility did not follow up with R1's risk of skin break down. A facility bed bath communication note dated January 23, 2023, R1 had a rash and redness on Buttocks, however, a reassessment was not completed. Moreover, the facility became aware that R1' was not able to complete safe transfers from their wheelchair to a shower chair. However, the facility did not reassess R1's functional capabilities in the following sections: bathing and transferring. In addition, the facility also, did not evaluate R1's acuity of care and if Apple Ridge Assisted Living facility staff could safely meet R1's needs after becoming aware that R1 could complete safe transfers from a wheelchair to a shower chair.

The following deficiencies were 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 the 809 report, 809-D page, and appeal rights 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: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/03/2023 03:06 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: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2023
Section Cited
CCR
87405(d)(1)

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87405(d)(1) Administrator - Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... This requirement was not met as evidence by: The Licensee did not ensure the Administrator was following R1's
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Facility Staff agrees for Administrator to review Administrator qualifications and Duties
regulation, and email LPA Martinez a formal
document stating the regulation has been
reviewed by POC Date 10/02/2023 by 5 PM
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discharge plan and following Basic Services Regulations. The Administrator choose to accept R1 for care, however, failed to meet R1 needs that were identified in the pre-admission appraisal and other facility appraisals. This posed a potential health and safety risk to R1.
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Type B
10/02/2023
Section Cited
CCR87463(a)(1)(2)(3)

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87463(a)(1)(2)(3) Reappraisals The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...This requirement was not met as evidence by: The Licensee did not ensure facility staff were conducting reassessment
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Facility staff agrees to conduct an All staff
in-service training on assessments by POC
date October 2, 2023. Facility staff agrees to
email training agenda and training documents
to LPA Martinez by POC date 10/02/2023
5 PM
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for R1's significant health changes, which
includes: skin breakdown/pressure injuries,
showers, and transferring. 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: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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