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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 03/07/2024
Date Signed: 03/20/2024 01:39:04 PM


Document Has Been Signed on 03/20/2024 01:39 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:
03/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Brittany RaganTIME COMPLETED:
02:15 PM
NARRATIVE
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On 03/07/2024 at 1:15 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez
met with Brittany Ragan and explained the purpose of the visit.

The purpose of the visit today is in response to an appeal determination and insufficient staffing citation:

Deficiency 87464(f)(2) Basic Services cited on 09/18/2023 has been changed to reflect 87464(f)(1) Basic Services. The Department has reviewed the appeal information, complaint details, and 9099 licensing report. It was determined a hoyer lift was recommended by the hospital upon discharge. However, a violations still exists for 22 CCR§ 87464(f)(1) as the facility did not provide a shower chair that would accommodate the resident as identified in the January 4, 2023 Pre-Placement Appraisal.

As a result, the 87464(f)(1) Basic Services deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code, which can be found on the 809-D Page. LPA Martinez provided a copy of the 809-D page to the facility. Citation (87464(f)(1) Basic Services is associated to complaint number 27-AS-20230131143919.

Additionally, 87464(f)(1) Basic Services cited on 09/18/2023 and was amended to reflect 87466 Observation of resident. The Department has reviewed the appeal information, complaint details, and 9099 licensing report. The facility acknowledge that R1 should have been more closely monitor, which shows a violation still exists. Additionally, the facility did not notate resident 1's skin condition and skin breakdown including redness and rash on buttocks. 87466 Observation of resident addresses the deficiency more appropriately.



Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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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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: 03/07/2024
NARRATIVE
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As a result, the 87466 Observation of resident deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code, which can be found on the 809-D Page. LPA Martinez provided a copy of the 809-D page to the facility. The citation (87464(f)(1) Basic Services) is associated to complaint number 27-AS-20230131143919.

Moreover, at today's case management visit, the facility was cited for insufficient care staff. During the appeal process, The Department reviewed the appeal information and complaint investigation details. Based on the prior Administrator's statements, showers were not provided when the facility was short staffed. Therefore, the facility will be cited a Personnel Requirements- General deficiency, and the deficiency can be found on the 809-D Page.



An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/20/2024 01:39 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2024
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: based on interviews, the Licensee did not ensure the facility had a
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POC implemented: Increased staffing 2 Med-techs at AM and PM shifts on AL side. 1 Med-Tech on Noc shift on AL side. Updated Med-Tech Job Description to included care staff duties. 3 Care staff on AM and PM for AL side. 1 Care Staff Mid-Shift from 11AM to 7:30 PM.
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sufficient amount of care staff to shower residents in care. As per the instruction of the prior Administrator, staff did not provide showers to residents when the facility was short staffed. This posed an immediate health and safety risk to residents in care and to resident 1.
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Memory Care Unit AM and PM shifts has 2 Caregivers. Mid-Shift Care Staff 11am to 7:30 PM. Added additional caregiver for the Noc shift on AL side. Added 1:1 behavior caregivers that will also provided care giving for all other residents if necessary. POC cleared at Visit.
Type A
03/07/2024
Section Cited
CCR87464(f)(1)

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87464(f)(1) Basic Services Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on observation, file review, and interviews, the Licensee
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POC implemented: Updated assessments/ reassessment process. Added a new software August health. Assessments are reviewed by Regional Wellness Director. POC cleared at visit
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Did not ensure R1 was provided a shower chair that would accommodate the resident as identified in the January 4, 2023 pre-placement appraisal. This posed an immediate health and safety risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/20/2024 01:39 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2024
Section Cited
CCR
87466

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87466 Observation of the resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by
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POC Implemented: Weekly wound tracker meeting. Weekly meeting with the Regional Nurse regarding skin integrity issues. POC cleared at visit.
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based on interviews and file review, the Licensee did not ensure staff were conducting skin checks and observing R1 for pressure injuries and ensuring appropriate assistance was provided when pressure injuries were observed on R1. This posed an immediate health and safety risk to R1
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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