347003117-12-7-2023-27-AS-KHOS-CYEKAD-20231211064346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:20:00 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
10/31/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20231031095912

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:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Erik Olson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility does not have an Administrator
Construction poses a risk to residents in care
Staff do not safeguard residents personal items
Facility is in disrepair (washing machine)
Staff do not prevent a resident from inappropriately touching other residents
Staff speak inappropriately to residents in care
Staff yell at residents in care
Staff do not meet resident needs
Staff do not ensure that the facility is secure

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings, LPA met with administrator Eric Olson and explained the purpose of the visit.

The Department has determined the following as it relates to the allegations: Facility does not have an Administrator, Construction poses a risk to residents in care, Staff do not safeguard residents personal items, Facility is in disrepair (washing machine), Staff do not prevent a resident from inappropriately touching other residents, Staff speak in appropriately to residents in care, Staff yell at residents in care, Staff do not meet resident's needs, Staff do not ensure that the facility is secure,

Cont on 9099-A and 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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 6

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
10/31/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20231031095912

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:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Erik Olson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not keep the facility clean and sanitary
Residents are left in the facility unsupervised by staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings, LPA met with administrator Erik Olson and explained the purpose of the visit.

The Department has determined the following as it relates to the allegations: Staff do not keep the facility clean and sanitary and Residents are left in the facility unsupervised by staff

Con't 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 27-AS-20231031095912

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: 12/07/2023

NARRATIVE

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On 12/04/2023 LPA Ivey Canady toured facility regarding current facility allegations. LPA observed the facility to be clean with new flooring throughout the facility. LPA observed facility staff cleaning the dining area after having served the morning meals. LPA toured the facility kitchen to include the cooking area and observed dishes being loaded and sinks being cleaned. LPA observed the stoves to be cleaned and no access food or crumbs on the ovens and floors. On 11/03/2023 LPA conducted interviews with facility staff and residents regarding cleanliness of the facility. 4 out of 4 residents reported rooms to be clean and showers to be cleaned after use. According to staff interviews additional facility clean staff has been hired over the past 4 weeks. Based on facility document review, facility has hired 2 additional cleaning staff. One has been hired for day shift and one has been hired for night shift. Therefore the allegation Staff do not keep the facility clean and sanitary is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/04/2023 LPA Ivey Canady toured the facility regarding current facility allegations. LPA observed there to be approximately 8 staff members in the front of the facility. LPA observed there to be approximately 4 staff in the kitchen area. LPA observed there to be 4 staff members in the facility management office. The current staff to resident ratio is 3 residents to 13 staff. According to interviews with facility staff, there has been 13 additional staff hired in the facility over the past 4 weeks. Based on interviews with staff in the prior four weeks there was a staff to resident ration of 8 staff to 5 residents. According to interviews with facility residents, 3 out of 4 residents report staff being available for assistance when residents request assistance. Based on interviews with facility residents 4 out of 4 report there staff in the facility 24 hours per day. Therefore the allegation Residents are left alone in the facility by staff is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. Exit interview conducted and report given to facility administrator Erik Olson.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 27-AS-20231031095912

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: 12/07/2023

NARRATIVE

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Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation regarding current facility allegations. On 11/15/2023 LPA visited the facility regarding current open complaints. LPA was introduced to new facility Administrator Erik Olsen who reportedly had been assigned to the facility on 11/13/2023. On 11/22/2023 LPA received all pertinent documents: LIC200, LIC308, LIC500, LIC501,LIC503, LIC508, LIC9182, facility updated LIC610E dated 11/15/2023, facility change of administrator letter and RCFE Administrator Certification assigned to Erik Olsen, from facility licensee showing Erik Olsen as facility administrator. Therefore, the allegation Facility does not have an Administrator is unsubstantiated.
An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/4/2023 LPA Ivey Canady toured the facility regarding current facility allegations. LPA observed the facility to be improved regarding current construction process. New facility flooring has been completed, all walls have been painted and all resident rooms have new dividers. The facility is quiet and there are no construction workers within facility during LPA visit. Based on interviews with staff and residents, residents are not in the vicinity of construction when construction is being done in the resident rooms. According to interviews with current residents and staff, the construction in the facility is winding down and the facility is in good repair. Therefore the allegation, Construction poses a risk to residents in care is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/04/2023 LPA Ivey Canady interviewed facility staff and residents regarding current facility allegations. According to interviews with staff, each resident has 2 night stand drawers that lock and have control over the keys to the personal drawers to store resident personal items. Based on interviews with residents, there have been no instances where personal belongings have gone missing. It was learned that residents are afforded to secure items with facility staff with a log in and out system designed to assist residents with small personal items that need to be temporarily secured. Based on facility documents to include facility Plan of Operation. Therefore the allegation, Staff do not safeguard residents personal items is unsubstantiated. .An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 27-AS-20231031095912

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: 12/07/2023

NARRATIVE

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On 12/04/2023 LPA Ivey Canady interviewed facility staff and residents regarding current facility allegations. According to staff interviews, and facility repair documents, the facility washing machines have been in repair. Based on facility documents there was an order placed for a new facility washing machine on 12/04/2023. Based on interviews with facility staff, the memory care side of the facility has 24 hour access to all laundry machines. Based on interviews with facility residents, there have been no issues with residents receiving and keeping clean laundry on a weekly basis. Therefore the allegation, Facility is in disrepair (washing machine) is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/04/2023 LPA Ivey Canady interviewed facility staff and residents regarding current facility allegations. The Department performed due diligence regarding current facility allegations to discover parties involved with any treatment toward facility residents that was against Title 22 regulations. Based on interviews performed with witnesses, facility staff and facility residents, the Department found no evidence for reported allegation Staff do not prevent a resident from inappropriately touching other residents. Therefore the allegation is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/04/2023 LPA Ivey Canady toured facility regarding current facility allegations. LPA observed staff to be engaging appropriately with facility residents. LPA observed facility staff to answer questions and assist residents with requests for assistance. On 11/15/2023 while touring the facility LPA observed R1 to be in distress. LPA observed facility staff assist R1 regarding a request of a motorized wheelchair that had not yet been approved via R1's insurance. LPA observed facility staff explain R1's insurance parameters to R1, ensuring R1 assistance would be given during R1's follow up medical appointment. According to interviews with additional facility residents, 4 out of 4 residents interviewed reported satisfaction with interaction with facility staff and 0 out of 4 reported witnessing staff yelling at residents. Therefore the allegations Staff speak inappropriately to residents in care and staff yell at residents in care is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20231031095912

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: 12/07/2023

NARRATIVE

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On 12/07/2023 LPA interviewed facility residents and staff regarding current facility allegations. The facility provided The Department with resident assessments, resident LIC602s and resident care plans. According to facility file reviews, resident care plans are adjacent to resident assessments and resident LIC602s. It was learned that on occasion, residents have been admitted to the facility based on information provided from the hospital they are being transferred from and the LIC602 may not have listed all requirements, in particular this was an occurrence with R5. Based on facility file review, the facility contacted the resident's physician and the facility was issued a new LIC602 and R5 was given a new assessment that is in alignment with facility care services that meets R5's needs. Therefore the allegation, Staff do not meet resident needs is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/04/2023 LPA Ivey Canady arrived to the facility unannounced and attempted to enter the facility via locked gate. LPA discovered facility gate code had been changed. According to interviews with facility staff, the facility gate code had been shared many times and in order to maintain security for the facility residents, facility management made the decision to change facility gate code. LPA conducted a tour of the facility grounds and checked north and south door entries to the facility and found all staff facility entrances to be locked and inaccessible unless a staff was available with the staff entry code. During the facility visit, LPA observed the front entrance to be unlocked for residents and visitors. LPA observed a sign posted at the facility entrance with a description of instructions for after hour entry. Therefore, the allegation Staff do not ensure facility is secure is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. Exit interview conducted and report given to facility administrator Erik Olson.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6