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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 10/18/2023
Date Signed: 01/22/2024 04:57:19 PM


Document Has Been Signed on 01/22/2024 04:57 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:ASHLEY SYLVEFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:82CENSUS: 64DATE:
10/18/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Steven Atlas, Michelle Hardy, Aaron Khodorkovsky, Jennifer Siege Joel Goldman and Brittany Ragan.TIME COMPLETED:
12:00 PM
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A Non-Compliance Conference (NCC) was conducted today on October 18, 2023 via Microsoft Teams with the Sacramento South Regional Office. Present at today's meeting include the following: Licensing Program Manager Stephenie Doub, Licensing Program Manager Czarrina Camilon-Lee, and Licensing Program Analyst Avelina Martinez, and Licensing Program Analyst Jamie Ivey-Canady: Facility Representatives: Steven Atlas, Michelle Hardy, Aaron Khodorkovsky, Jennifer Siege, Brittany Ragan, and Joel Goldman.

The non-compliance conference process was explained during this meeting to include the Administrative process.

In the last five years, the facility has been cited a total of eight times. The facility received four: A citations and 4: B citations. The citations consist of the following: Basic Services, observation of the resident, personal rights, administrator qualifications, reappraisals, and incidental and medical

Issues discussed during the Non-Compliance Conference were:
  1. Administrator Changes
  2. Care and Supervision
  3. Incidental and Medical
  4. Basic Services
  5. Assessments and Reassessments
  6. Personal Rights
  7. Observation of residents

Continued...

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/18/2023
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The facility has stated they will do the following to achieve continued and substantial compliance:
  • Submit facility training documentation to Community Care Licensing Department (CCLD)
  • Request Technical Support Program (TSP) if needed.
  • Submit fire clearance documentation to Regional Manager.

In addition, at this meeting the Licensee and management company were advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action.

Community Care Licensing Department (CCLD) will do the following:

  • Increase monitoring to quarterly visits.
  • Technical Support Program (TSP) referral. (Licensee accepted TSP services, and a referral will be completed when Licensee advises CCLD of TSP need.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited at this visit. An exit interview was conducted with facility staff, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
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