347003117-8-6-2024-27-AS-KHOS-D84HYY-20240813063731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:19:41 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2024 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20240522142537

FACILITY NAME:	APPLE RIDGE ASSISTED LIVING		FACILITY NUMBER:	347003117
ADMINISTRATOR:	AARON KHODORKOVSKY		FACILITY TYPE:	740
ADDRESS:	3950 ANNADALE LANE		TELEPHONE:	(916) 489-6900
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	0	CENSUS: 85	DATE:	08/06/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Alfredo Cruz		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff are not properly dispensing medication as prescribed.

INVESTIGATION FINDINGS:

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On 8/6/2024, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to complete and delivery findings for a complaint investigation received on 5/22/2024. LPA met with Administrator Designee Alfredo Cruz and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on records review and interviews, it was determined that facility staff are not properly dispensing medication as prescribed. It was learned that several of R1's medications which includes Folic Acid, Pregabalin, and Trazodone ran out at different time during the time frame from March to May of 2024. R1 corroborated that R1 was missing medications weeks at a time due to medication refills were not done timely. R1 corroborated that R1 was hospitalized twice due to missing medications during time frame above.

Report continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240522142537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/06/2024

NARRATIVE

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Based on staff interviews, staff stated R1 revealed that R1 doesn’t have a medical provider upon admission; therefore, the facility attempted to pair R1 with another provider. Staff stated follow-ups were made with R1's new provider; however, R1’s new provider and pharmacy did not provide the medications timely. Ultimately, it was determined that the facility did not ensure R1’s receive medications as prescribed.

Based on interviews conducted, and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. This allegation was substantiated and cited on previous complaint, control number: 27-AS-20240429163338 and has been resolved.

Exit interview was conducted, a copy of report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC9099 (FAS) - (06/04)

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