347003117-11-30-2023-27-AS-LKIG-CYALL5-20231207075031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 11/30/2023
Date Signed: 11/30/2023 09:51:27 AM

Substantiated

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
09/28/2023 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230928094441

FACILITY NAME:	APPLE RIDGE ASSISTED LIVING		FACILITY NUMBER:	347003117
ADMINISTRATOR:	ASHLEY SYLVE		FACILITY TYPE:	740
ADDRESS:	3950 ANNADALE LANE		TELEPHONE:	(916) 489-6900
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	82	CENSUS: 64	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Brittnay Ragan and Eric Olsen		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff did not prevent resident from being physically abused by another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 11/30/2023 at 8:30 AM to deliver complaint findings, LPA met with Brittnay Ragan and Eric Olson and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed medical documents, and reviewed facility records. R1's July 03, 2023 Service Plan indicated R1 was ranked at a level 5 and sixty-eight points. The July, 03, 2023 Service Plan also, reported R1 has history of physical aggression or violence. On July 10, 2023, R1 had a change in condition. R1 was experiencing confusion and was sent to the Emergency Room (ER). Moreover, 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. The letter also reported R1 is no longer safe to himself and others in a licensed care facility setting. After the September 10, 2023 ER visit and the September 11, 2023 letter, R1 was not reassessed. Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20230928094441

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: 11/30/2023

NARRATIVE

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R1 was not reassessed until October 17, 2023. The October 17, 2023 Service plan ranked R1 at level six with eighty-three points. Moreover, R1 was not provided 1:1 care and supervision until October 06, 2023. R1 receives 1:1 care and supervision for a total of sixteen hours a day. R1 has a 1:1 caregiver from 8:00 AM to 4:00 PM and 4:00 PM to 12:30 AM. R1 does not receive 1:1 care and supervision from 12:30 AM to 8 AM. Facility caregivers working the PM and NOC shift provide care and supervision to R1. During the NOC shift, there is one caregiver and one med-technician working in the Assisted Living (AL) unit, which they oversee 52 residents. Furthermore, R1's October 17, 2023 Service Plan indicates R1 has disruptive sleep patterns/inconsistent sleep patterns, wanders, and elopement risk. It was determined R1's 1:1 care needs from 12:30 AM to 8:00 AM needs are not being met.

In addition, it was learned R1 has been in multiple altercations with other residents in care. During these altercation R1 did not have a 1:1 caregiver present. On May 23, 2023, R1 was in an altercation with another resident that required both residents to be sent to the Emergency Room (ER). R1 was in another altercation that involved three other residents on July 18, 2023. As a result of the July 18, 2023 altercation, three residents were sent out the ER. Law Enforcement was called out to the facility on September 24, 2023 due to R1 getting into a physical altercation with another resident. R1 was also in a physical altercation on September 27, 2023. Staff reported they found R1 on the ground interlocked with another resident. Staff reported they were able to separate both residents. Resident 2 (R2) was sent out the ER. R2 had bleeding on his right elbow, discoloration on his is right temple, and a small bleeding area on his left cheek near his ear. R1 had no visible injuries, however, R1 was sent out to the ER.

It was determined the facility did not prevent R2 from being physically abused by R1 on September 27, 2023. Due the fact, facility staff were aware of R1's aggressive behaviors towards residents and did not implement a service plan to meet R1's behavior care needs. Additionally, the facility did not meet R1's required 1:1 care and supervision needs during the altercations. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Additionally, please refer to 11/30/2023 case management for other deficiencies learned during this complaint investigation. continued...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20230928094441

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/04/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1(a)(3) Personal Rights of Residents in All Facilities: To be free from punishment, humiliation, intimidation, abuse... This requirement was not met as evidence by: based on file review and interviews, the Licensee did not ensure R2 was free from abuse. The facility was aware that R1 had	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	aggressive behaviors towards residents and didn't not implement a plan to address R1's aggressive behaviors, and keep R2 safe. In addition to, not preventing R1 from beating up R23 during the 09/27/2023 incident. This posed an immediate health and safety risk to R2 and other residents in care.	8 9 10 11 12 13 14
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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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20230928094441

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: 11/30/2023

NARRATIVE

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Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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