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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003117
Report Date: 05/19/2023
Date Signed: 06/20/2023 01:48:36 PM


Document Has Been Signed on 06/20/2023 01:48 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:APPLE RIDGE ASSISTED LIVINGFACILITY NUMBER:
347003117
ADMINISTRATOR:ASHLEY SYLVEFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:82CENSUS: 57DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brittany Ragan, Jennifer Siegel TIME COMPLETED:
02:30 PM
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On May 19, 2023, a meeting was conducted virtually, via Microsoft Teams. The purpose of this meeting was to discuss Noro Virus Outbreak and Infection Control Plan. Present in the meeting were Community Care Licensing Department (CCLD) Licensing Program Manager Stephenie Doub, Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst Avelina Martinez. Facility Representatives: Brittany Ragan, Jennifer Siegel.

During the meeting, the following items were discussed:
  • Positive Noro Virus Cases Update
  • Infection Control/Mitigation Plan
  • Line List
  • PPE Use and Facility Supply
  • Staff and Resident Noro Virus Symptom Monitoring
  • Staffing (No issues and has staffing agencies in place)

The facility has stated They have implemented the following Infection Control Plan:
  • Disinfecting cleaning
  • PPE training for staff
  • PPE stations throughout the facility
  • Closed dinning area and using disposable meal utensils and dishware
  • Closed activities
  • Facility closed to visitors and open to essential health workers.
  • Implementing Isolation precaution practices
  • Implementing hand hygiene practices for staff and residents

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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: 05/19/2023
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Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with Jennifer Siegel, 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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