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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:14:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230802142726
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: 65DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Yvonne EmmanuelTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff mismanage resident's medication
Staff refuse to allow resident to manage medication
Staff did not safeguard resident's personal item
Resident's bathroom is not clean
Staff do not assist resident with hydration needs
Staff do not respond to resident's call button timely
Staff do not assist resident with showering needs
Staff do not afford resident respect in their relationship
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/26/2023 at 1:00 PM to deliver complaint findings, LPA Martinez met with Yvonne Emmanuel, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, toured the facility, and reviewed facility records. Facility documentation dated August 03, 2023, indicates Med-tech 1 (MT1) administered resident 1 (R1) their medication. However, R1 refused the medication being administered by MT1 on August 03, 2023, as R1 believed it was the incorrect medication. Staff documentation indicates MT1 went over the bubble pack orders and medication with R1. In addition, MT1 informed R1 that the medication that was being administered was correct. As a result, there is not a sufficient amount of evidence to prove a medication error occurred on August 08, 2023. It was learned R1 was provided the option to administer their own medication. The facility requested prior to R1 managing their own medication that they obtain a lock box for medications. Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 3
Control Number 27-AS-20230802142726
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 LIVING
FACILITY NUMBER: 347003117
VISIT DATE: 10/26/2023
NARRATIVE
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In addition to, following facility policy that allows an appropriate designated senior community management staff to have the ability to access medications in the event of an emergency. It was reported that R1 refused to allow facility staff to have access to their medications. It was also reported the facility requested R1 to complete a medication self-management assessment, and facility staff indicated R1 refused to complete the assessment. However, R1's Health Certification form LIC 602 indicated R1 was able to manage their medications. Staff 1 (S1) reported R1 was allowed to administer their medication due to the fact that the LIC 602 Health Certification form stated R1 was allowed to manage their medication. S1 reported R1 stored their medications at their room, and they managed the refilling of their medication. Due to the information provided, there was not a sufficient amount of evidence to prove the facility did not allow R1 to manage their own medication.

It was also learned R1 was missing bingo cards. However, R1's property inventory list did not include bingo cards. Therefore, there was not enough evidence to show the facility did not safeguard R1's property. It was learned R1 no longer resides at the facility, as a result, LPA Martinez inspected multiple resident bathrooms. LPA Martinez also, conducted six resident interviews. Six out of six residents reported their bathrooms were clean, and LPA Martinez observed restrooms to be clean. There is not a sufficient amount of evidence to prove resident bathrooms are not being cleaned. Moreover, LPA Martinez reviewed resident housekeeping records for the month of August 2023. It was learned R1's bedroom was cleaned six times for the month of August 2023. In addition, residents can request their bathroom to be cleaned at any time. Moreover, bowel and bladder accidents are cleaned up at the time of the incident.

It was learned the activities director provide hydration liquids to residents three times per day. The facility has a hydration station located at the dinning room area. Residents are able get water and ice at the hydration station. Residents can also use their call buttons to request drinks. Furthermore, the facility does not have any written record that R1 was not provided water. There is not a preponderance of evidence to prove R1 was not offered or provided water. LPA Martinez reviewed R1's August 2023 call button log. The call button logs were not complete. The call log indicates staff were responding to R1's pages. However, R1's pages were not cleared on the call button system by staff. It is unknown if the time indicated on the call log is correct. As a result, there is not enough evidence to prove that R1 was waiting for a long period of time. The facility has no documentation stating that R1 was not provided showers. S1 reported showers were being provided. S1 also reported R1's family would assist R1 with showers. Based on the interviews conducted during the investigation process, the allegation cannot be corroborated.
Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230802142726
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 LIVING
FACILITY NUMBER: 347003117
VISIT DATE: 10/26/2023
NARRATIVE
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Based on the interviews conducted during the investigation process, allegation "Staff do not afford resident respect in their relationship" cannot be corroborated.

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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3