347003117-5-4-2023-27-AS-CACL-CRPLD7-20230510083929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 05/04/2023
Date Signed: 05/04/2023 09:41:13 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221216150900

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: 56	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained a serious injury while under the care and supervision of the facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/04/2023 at 9:30 am, Licensing Program Analysts (LPA) Avelina Martinez and Pang Lee arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Ashley Sylve during today’s visit.

Throughout the course of this investigation, the Department conducted interviews and reviewed facility records. The investigation revealed resident 1 (R1) had a history of aggressive behaviors. The facility was conducting reassessment to meet R1's needs, however; due to R1's increasing aggressive behaviors, R1 was no longer responsive to re-direction. As a result of R1 increasing aggressive behaviors, R1 was transferred to a higher level of care facility. Due to the above noted information there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

An exit interview was conducted, and a copy of this report was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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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