347003117-11-15-2023-27-AS-KHOS-CYEKD7-20231211064816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:13:39 PM

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
11/08/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20231108082819

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:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Eric Olsen		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not follow infection control practices

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unannounced facility visit to open a complaint investigation with the above allegations and deliver complaint findings. LPA Ivey Canady met with current facility administrator Eric Olsen and explained the purpose of today's visit.

LPA Ivey Canady requested, received and reviewed the following facility documents: Administrator personnel file, LIC308, updated LIC500, updated facility covid positive line list.

The Department has determined the following as it relates to the allegations: Staff do not follow infection control practices.

Cont on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231108082819

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: 11/15/2023

NARRATIVE

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On 11/15/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady visited the facility regarding current complaint allegations. On 11/07/2023 while visiting the facility to open complaint #27-AS-20231103105937, LPA observed facility staff to not be wearing masks and 2 facility staff to have masks on under the chin. On 11/07/2023 LPA spoke with facility staff and reminded staff of infection control practices and asked staff to wear masks due to the Covid 19 outbreak at the facility that had been reported to LPA by facility administrator on 11/06/2023. On 11/15/2023, LPA observed approximately 6 out of 10 staff members not to be wearing masks while in the facility. LPA observed approximately 5 out of 10 staff members to have masks on under the chin while walking through the facility. LPA did not observe any hand washing signs, hand sanitizer or PPE stations in the facility. LPA observed the facility to not have any Covid19 signs posted throughout the facility. According to staff interviews, the Covid positive signs have been removed from the facility because the majority of the residents who had tested positive are now testing negative. However, based on staff interviews, there are facility staff who are unaware that there are still Covid positive residents in the facility. Based on LPA observation, facility is not following Title 22 approved infection control plan. LPA did not observe any facility residents to be wearing masks. Therefore, the allegation Staff do not follow infection control practices is Substantiated.
Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231108082819

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: 11/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/15/2023 Section Cited CCR 87470(b)(2)	1 2 3 4 5 6 7	87470 Infection Control Requirements (b)In addition to subsection (a), when one or more residents in the facility are diagnosed...(2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE)...This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated staff will do an immediate training in service with all staff and will provide LPA a sign in sheet No Later Than (NLT) 11/16/2023
	8 9 10 11 12 13 14	Based on LPA observations and facility staff interviews, the licensee did not ensure facility staff and residents followed Title 22 Infection Control Practices. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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