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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 04/11/2024
Date Signed: 04/11/2024 09:53:29 AM


Document Has Been Signed on 04/11/2024 09:53 AM - 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: 74DATE:
04/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alfredo CruzTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with executive director Alfredo Cruz and explained the purpose of the visit.

LPA Moleski reviewed three incident reports received on April 5, 2024. The incident reports described a former employee (S1) administering injections to three residents on April 3, 2024 (R1-R3). The injections were witnessed by a medication technician (S2) who reported the incidents to management. S1 admitted administering the injections, rather than assisting the residents with self-injections, because it would save time, according to Cruz.

S1 was suspended after the incidents were reported to management, and later resigned. A staff training for all medication technicians is planned for next week, according to Cruz.

This facility is being cited per 22 CCR Section 87465(a)(5). An exit interview was held with Cruz. Appeal rights and a copy of this report were left with Cruz.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/11/2024 09:53 AM - 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: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
87465(a)(5)

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"(5) Facility staff, except those authorized by law, shall not administer injections..."
This requirement was not met as evidencd by:
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Licensee has already scheduled a training for medication technicians. Licensee agrees to send LPA Moleski a copy of the training sign-in sheet after completion.
vincent.moleski@dss.ca.gov
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Based on record review, a staff member (S1) administered injections to three residents on April 3, 2024, which poses an immediate health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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