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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:05:44 PM


Document Has Been Signed on 02/22/2024 03:05 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: 69DATE:
02/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Jennifer SigelTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced. LPA Ivey Canady met with Jennifer Sigel and Brittany Ragan and explained the purpose of today's visit.

LPA received notification from recent Administrator Erik Olson on 2/13/2024 that he is no longer administrator at the facility. According to facility Regional Nurse Jennifer Sigel, she is temporarily the administrator for the facility and attending the facility at least 20 hours per week. LPA Ivey Canady requested and received a current copy of the facility LIC308.

The purpose of today's visit is to conduct a quarterly visit in regard to the Non-Compliance Conference (NCC) held with the facility staff on 10/18/2023.

In accordance to the NCC meeting the following are updated: On 12/18/2023 Community Care Licensing (CCL) reports having received copies of facility fire clearance. LPA Ivey Canady has received facility training documents from previous facility administrator. Facility renovations are complete.

Documents requested and received during today's visit: Current copy of facility LIC308, updated facility LIC500.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies cited. Exit interview was held and a copy of report was given to facility administrator Jennifer Sigel.


SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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