347003117-1-12-2024-27-AS-KHOS-CZRJ2F-20240123053949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:10:25 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
10/18/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20231018154021

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: 66	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Erik Olson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Licensee does not ensure staff are adequately trained
Staff do not ensure sufficient supervision is provided to residents in care
Facility is in disrepair
Staff do not ensure residents have fresh clean clothing at all times
Staff do not ensure residents have access to running water

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 Olsen and explained the purpose of the visit.

The Department has determined the following as it relates to the allegations: Licensee does not ensure staff are adequately trained, Staff do not ensure sufficient supervision is provided to residents in care, Facility is in disrepair, Staff do not ensure residents have fresh clean clothing at all times, Staff do not ensure residents have access to running water

Cont on 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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20231018154021

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: 01/12/2024

NARRATIVE

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On 10/24/2023, 11/07/2023, 12/07/2023 and 1/12/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation into facility allegations. According to facility staff files, and facility training files, facility staff have received in-service training on 12/19/2023 regarding implementing the facility infection mitigation plan to include mask wearing, how to receive visitors during an infection outbreak, dining, events, activities and outings. On 11/16/2023 facility introduced in-service training to 23 staff members regarding Center for Disease Control (CDC) Guidelines. On 12/6/2023 18 facility staff members received training on the facility new badge system and on 1/4/2024, 27 facility staff members received in-service training on the topic of the facility's Personal Property Theft and Loss Policy. Based on interviews with facility staff, new employee training occurs within the first week of hire and the new hire is given facility training along with facility staff shadowing for approximately 2 weeks before proceeding to designated positions solo. Therefore, the allegation, Licensee does not ensure staff are adequately trained 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 10/24/2023, 11/07/2023, 12/07/2023 and 1/12/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation into facility allegations. According to facility resident files, and facility staff schedule, facility memory care residents are on a 1:1 AM and PM schedule. Based on the facility Rehabilitation Proposed Program Schedule for R1, there are 2 hour incremental activities and goals 24 hours per day that include staff breaks to ensure R1 is never left alone. Based on interviews with facility staff, the proposed scheduled is followed daily. Based on facility chart notes, facility staff is following proposed program schedule for R1. Based on facility staff interviews, there is a facility Rehabilitation Proposed Program Schedule and a 1:1 ratio for all facility memory care residents. Therefore the allegation Staff do not ensure sufficient supervision is provided 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.

Cont on 9099-C

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: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20231018154021

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: 01/12/2024

NARRATIVE

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On 10/24/2023, 11/07/2023, 12/07/2023 and 1/12/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation into facility allegations. During LPA facility tour, LPA observed facility to be finishing facility upgrades, construction and renovation. On 12/07/2023, LPA observed facility dining area to be free of boxes and newly installed dining furniture placed throughout the dining area. Based on interviews with facility residents, facility renovations are completed to include newly installed showers and flooring in resident rooms. According to facility resident interviews, 4 out of 4 residents are satisfied with facility upgrades. Based on facility staff interviews, facility renovation took approximately 3-4 months and no residents were displaced due to facility renovations. Based on LPA observation during facility tour, facility is in good repair and there are no construction hazards throughout the facility. Therefore the allegation, Facility is in disrepair 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 10/24/2023, 11/07/2023, 12/07/2023 and 1/12/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation into facility allegations. According to facility appliance purchase records, facility purchased a high capacity washing machine and dryer on 10/26/2023. According to facility purchase records, on 9/24/2023, facility purchased a new high capacity washing machine. Based on interviews with 4 out of 4 residents, no resident reports having problems with laundry services. According to interviews with facility staff, during the month of September, facility memory care shared laundry servicing machines with facility assisted living until new facility washing machine was delivered. According to interviews with facility staff, all facility residents maintained clean laundry services during the transition to new laundry machines. Therefore the allegation, Staff do not ensure residents have fresh clean clothing at all times 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: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20231018154021

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: 01/12/2024

NARRATIVE

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On 10/24/2023, 11/07/2023, 12/07/2023 and 1/12/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation into facility allegations. On 10/24/2023, LPA Ivey Canady toured facility kitchen, and resident bathroom areas and observed running water in all faucets and sinks. Based on interviews with 3 out of 4 residents, there have been no issues with water services throughout the facility. According to facility record reviews, and a facility document dated 1/5/2024 detailing finalization of facility construction improvements and renovations, there is one countertop installation in the living room area and the replacement of tiles in one shower room are scheduled in the upcoming weeks. According to interviews with facility staff, facility construction crew staggered plumbing renovations, from one side of the facility to the other, to ensure the facility had a steady flow of running water on either side of the facility at all times. Therefore the allegation Staff do not ensure residents have access to running water 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.

In Accordance with Title 22, No Deficiencies have been cited, an exit interview was conducted, and a copy of this report was provided to the facility.

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: 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

LIC9099 (FAS) - (06/04)

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