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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 11/30/2023
Date Signed: 11/30/2023 09:53:49 AM


Document Has Been Signed on 11/30/2023 09:53 AM - 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:AARON KHODORKOVSKYFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:82CENSUS: 63DATE:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Brittnay Ragan and Eric OlsenTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst Avelina Martinez arrived at this facility unannounced on 11/30/2023 at 8:30 AM to conduct a case management visit. LPA met with Brittnay Ragan and Eric Olson and explained the purpose of the visit.

The purpose of the visit is to follow up on learned deficiencies during complaint investigation 27-AS-20230928094441.

It was learned resident 1 (R1) was not being reassessed after change in conditions. During 27-AS-20230928094441 complaint investigation, LPA Martinez requested R1's assessments. LPA Martinez was given service plans dated July 03, 2023 and October 17, 2023. LPA Martinez did not receive a pre-placement assessment. In addition, LPA Martinez received a December 02, 2022 Assisted Living Waiver Program (ALWP) Individualize Service Plan (ISP).

It was learned R1 had experienced a change in condition on July 10, 2023. R1 was experiencing confusion and was sent to the Emergency Room (ER). upon R1's return to the facility, R1 was not reassessed. during a file review, a letter from R1's medical physician dated September 11, 2023 indicated a licensed care facility setting was not appropriate for R1 due to their challenging behaviors. R1 was not reassessed after receiving the September 11, 2023 letter.

Based on the obtained documents from the facility and interviews, deficiencies were cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the LIC 809 D-Page. An exit interview was conducted, and a copy of this 809 report, 809-D page, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/30/2023 09:53 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2023
Section Cited
CCR
87463(a)

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87463(a) 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:
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Facility staff agrees to: review R1's behavior plan that includes R1's 1:1 care needs. By POC Date 12/4/23. Facility staff will email LPA Martinez an updated Service Plan by POC date 12/04/23 5PM R1: Currently has a 1:1 caregiver for 16 hours a day.
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Based on file review and interviews, the Licensee did not ensure R1 was being reassessed after resident on resident altercations/behavior changes/confusion memory health condition changes. This posed a potential health and safety risk to resident 1.
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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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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