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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 01/27/2022
Date Signed: 01/27/2022 12:13:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:APPLE RIDGE ASSISTED LIVINGFACILITY NUMBER:
347003117
ADMINISTRATOR:MICHELLE HARDYFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:82CENSUS: 22DATE:
01/27/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley SylveTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual inspection on 01/27/2022. LPA met with Ashley Sylve and explained the purpose of the visit. Ashley Sylve is the Administrator and holds certificate #6059192740 and expires on 3/24/2023

This facility is a single story with 2 buildings licensed to serve eighty two (82) residents. Annadale building is licensed to serve 58 non ambulatory and 12 bed ridden residents. Auburn building is licensed to serve 12 bedridden and a hospice waiver for 6 residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, and outside building and grounds. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (111) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. All fire extinguishers last serviced 07/18/2021. Thermostat observed at (72) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.
LPA received copy of staff roster, resident roster, LIC 308, and certificate of liability insurance during today's visit.

There were no deficiencies cited during today's inspection. Exit interview held with Ashley Sylve and a copy of report given at the conclusion of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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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