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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 03/08/2023
Date Signed: 07/31/2024 10:21:50 AM


Document Has Been Signed on 07/31/2024 10:21 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, 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: 63DATE:
03/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ashley Slyve TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Ashley Slyve and explained the purpose of the visit.

The purpose of the visit today, is in response to a learned reporting requirement deficiency. During complaint 27-AS-20230307110939 investigation, it was learned the facility had cases of Scabies, however, it was not reported to the Department. As a result, the following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency can be found on the 809-D page.

An infection control plan shall be implemented and skin check line list shall be completed for all staff and residents. In addition, Local Public Health shall be informed of the two cases of Scabies.

Exit interview conducted, and a copy of this 809 report and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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 07/31/2024 10:21 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require...A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence
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Facility Administrator agrees to conduct reporting training for all staff by POC date 03/22/23. Facility Administrator agrees to email training documentation by POC date 03/22/23 by 5 PM.
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Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidence by: Based on record review and interview: the facility did not report R1 Scabies health condition. This posed a potential health 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2