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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:48:34 PM


Document Has Been Signed on 04/22/2024 12:48 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: 74DATE:
04/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Alfredo CruzTIME COMPLETED:
01:00 PM
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 two incident reports. The first described an incident which occurred on 4/11/24. A resident (R1) was given a roommate's medication, including a narcotic and a blood thinner. First responders were called but R1 refused immediate transport, according to the incident report. The resident was at the hospital during this visit and was unable to be interviewed. The staff member who erroneously provided R1 with the wrong medication (S1) was working for a staffing agency. Cruz said that he notified the agency that he would not like S1 to return to the facility. LPA Moleski asked for any training records on file for S1. Cruz provided a one-page orientation which described general duties to agency staff. The orientation sheet instructed agency staff to verify residents' identities before passing out medications.

The second incident report described an instance of alleged abuse which occurred on 4/9/24. According to the incident report, a resident (R2) alleged that a staff member (S2) pushed R2 to the floor. According to the incident report, S2 claimed that R2 had slipped onto the bed, but had not fallen onto the floor. LPA Moleski interviewed R2 during this visit. R2 said that S2 pushed R2 while transferring. R2 said that S2 had never physically abused R2 previous to this incident. R2 said that the door to the room was closed and nobody else was present to witness the incident.

LPA Moleski interviewed S2 over the phone. S2 said that R2 let go of the bed during the transfer and fell onto the bed. S2 said another staff member came to assist R2 afterward. LPA Moleski interviewed S3, who arrived in the room after hearing screams coming from R2's room. S3 said R2 was kneeling on the ground between the wheelchair and the bed upon entry.

[continued on 809-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
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 3


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: 04/22/2024
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After learning of the incident, Cruz reported it to CCLD, to local law enforcement, and to the ombudsman's office. Cruz immediately suspended, then terminated, S2.

This facility is hereby cited per 22 CCR Section 87465(a)(4) regarding the medication error described above. Sufficient evidence does not exit to prove facility responsibility for the alleged physical abuse described above. 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: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/22/2024 12:48 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: 04/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2024
Section Cited
CCR
87465(a)(4)

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"(4) The licensee shall assist residents with self-administered medications as needed."
This requirement was not met as evidenced by:
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Licensee has already asked S1 not to return and has added photos of residents to the EMARs to prevent future mistakes.
Licensee agrees to send LPA Moleski a screenshot showing R1's photo has been added to the EMARs by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interview with Cruz, a resident was given incorrect medications, including narcotics and blood thinner, 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: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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