347003117-12-11-2023-27-AS-CACL-CYQN7S-20231221091314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:01:35 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
11/03/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20231103105937

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: 63	DATE:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Erik Olson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not ensure that medication is stored locked and inaccessible to residents

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.

LPA Ivey Canady requested, received and reviewed the following facility documents: Facility medical files, facility chart notes. LPA Ivey Canady performed interviews with facility residents, witnesses and staff.

The Department has determined the following as it relates to the allegations: Staff did not ensure that medication is stored locked and inaccessible to residents

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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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-20231103105937

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: 12/11/2023

NARRATIVE

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On 11/06/2023 LPA Ivey Canady conducted interviews with witness regarding current facility complaint allegations. According to witness, an unidentified medicinal pill was found on the floor of the facility. Witness forwarded the unidentified medication to Community Care Licensing (CCL) in care of LPA. It was learned there was no photo placing the unidentified medicinal pill in the facility. Based on interview with facility staff, there is no knowledge of facility medtechs misplacing or dropping any medication. According to interviews with facility staff, facility chart note reviews and facility medical files, there are no missing medication or dosages listed in facility documents. Based on facility staff interviews, there are no identifiers that place the unidentified medication in the facility. On 11/15/2023 LPA conducted a tour of the facility and observed medication cabinets to be locked and inaccessible to facility residents. According to facility resident interviews, assistance with medication is completed in a timely fashion daily and 2 out of 2 residents report no missing dosages. Therefore the allegation, Staff did not ensure that medication is stored locked and inaccessible to residents 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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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