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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:08:04 PM


Document Has Been Signed on 01/12/2024 03:08 PM - 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: 66DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Erik OlsonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady made an unannounced visit to this facility to conduct an annual inspection. LPA met with Erik Olson and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator certificate expired on December 10,2023, Administrator has submitted all pertinent paperwork for renewal. The facility is licensed for 82 residents, which 58 can be non-ambulatory and 12 can be bedridden and in the memory care building there can be 12 bedridden. The facility has a hospice waiver for 6 residents. There are currently 3 residents on hospice. There are currently 66 residents who reside at this facility.

During today's annual visit, the facility was sanitary and clean. In addition, the facility has an activities calendar posted. The facility has a new modernized reception area. The facility also has a food menu. LPA toured the facility Kitchen, and it was sanitary and clean. The facility has an adequate food supply. The facility has 3 chefs and 6 kitchen staff. The facility water temperature measured at 110 degrees F which meets the 105-120 degree Fahrenheit regulation. The facility temperature measured at 77 degrees. LPA Ivey Canady reviewed five staff files and five resident files. The facility files were up to date.

Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharps kept locked and inaccessible to clients. LPA reviewed fingerprint clearance and associations to the facility. Facility grounds are in good condition with no foreseeable hazards or health cautions for persons in care.



Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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