347003117-3-23-2023-27-AS-AMAZ-CQ7T28-20230323142018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 03/15/2023
Date Signed: 03/23/2023 02:20:23 PM

Document Has Been Signed on 03/23/2023 02:20 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	APPLE RIDGE ASSISTED LIVING		FACILITY NUMBER:	347003117
ADMINISTRATOR:	MICHELLE HARDY		FACILITY TYPE:	740
ADDRESS:	3950 ANNADALE LANE		TELEPHONE:	(916) 489-6900
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	82	CENSUS: 63	DATE:	03/15/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	11:00 AM

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On March 15, 2023, a meeting was conducted virtually, via Microsoft Teams. The purpose of this meeting was to discuss Scabies and Infection Control Plan. Present in the meeting were Community Care Licensing Department (CCLD) Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst Avelina Martinez, DSS Nurse Cristina Wong, facility representatives include: Ashley Sylve, Brittany Ragan, Jennifer Siegel, and Local Public Health (LPH) representatives, Lindsey Park, Karen Collins.

During the meeting, the following items were discussed:

Positive Scabies Cases Update
Infection Control Mitigation Plan
Line List
PPE Use
Staff and Resident Scabies Symptom Monitoring
Reporting Requirements Per Title 22; Scabies Outbreak of residents and residents’ responsible parties

The facility has stated they will do the following:

Provide Employee/Resident Scabies/Rash Line List to CCLD and LPH.(Weekly)
Continue to implement Rash/Scabies Infection Control Plan.
Monitor residents and staff for rash/Scabies symptoms- until April 14, 2023, If no new Scabies cases arise.
Provide weekly rash/Scabies updates to CCLD and LPH.
Immediately report new rash/Scabies case to CCLD and LPH.

CONTINUED...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: APPLE RIDGE ASSISTED LIVING	FACILITY NUMBER: 347003117
	VISIT DATE: 03/15/2023

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Requested Documents:
Staff and Resident Scabies/Skin Check Line List (Submit Weekly)
Resident 1’s LIC 602 Physician’s Report (that’s the title of the 602) Health Certification Form. Submit via email to LPA Martinez by 03/17/2023 By 5:00 PM.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with Ashley Slyve, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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