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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 10/30/2023
Date Signed: 10/30/2023 03:09:36 PM


Document Has Been Signed on 10/30/2023 03:09 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
10/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lisa JohansenTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced regarding the incident report dated 10/21/2023 submitted to the Department. LPA Ivey Canady met with business office manager Lisa Johansen and explained the purpose of today's visit.

Community Care Licensing (CCL) received an incident report regarding Resident 1 (R1) having been found to have illegal drugs in the facility. According to the incident report, the Sacramento County Sheriffs office was called by the facility and the drugs were removed from the facility. R1 was not removed from the facility at the time of the Sheriffs response to the call.

Adult Protective Services and the Sacramento County Ombudsman were notified. The facility offered R1 to be taken out for medical care and R1 has refused medical services.

According to the business office manager, the facility will continue to conduct daily room sweeps. To ensure the health and safety of all residents in the facility, the sweeps are generally conducted after R1 returns from being out of the facility for approximately 5 or 6 hours.

The facility will continue to monitor R1 closely over the next 4 weeks and reassess R1's eligibility to continue in the facility as a resident. The reassessment report will be forwarded to the facility LPA no later than (NLT) 11/30/2023.



Per California Code of Regulations, Title 22,  no deficiencies were observed during this visit. Exit interview was held and a report was given to facility manager Lisa Johansen.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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