347003117-6-22-2023-27-AS-KHOS-CT9HWM-20230629063346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 06/22/2023
Date Signed: 06/22/2023 09:10:44 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
11/28/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221128085851

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:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lisa Johansen		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not provide adequate supervision to meet resident's need.
Staff do not ensure resident's equipment is secure.
Staff do not ensure resident's room is clean.
Administrator has not responded to resident's POA.
Staff do not assist residents with incontinence needs.
Residents are not fed timely.

INVESTIGATION FINDINGS:

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On 06/22/2023 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Lisa Johansen during today’s visit.

Throughout the course of this investigation, LPA Martinez conducted interviews, tours of the facility, and reviewed facility records. LPA Martinez inspected resident 1's (R1) room on various visits and observed the room to be clean. Additionally, R1 reported having no issues with the cleanliness of their room. During a facility visit, LPA Martinez found that R1's medical equipment was secured. In addition, LPA was informed by R1 that they had no issues with their incontinent care. LPA Martinez made an additional facility visit on 04/26/2023, and LPA Martinez observed R1's bedroom and bathroom to be clean and sanitary. Furthermore, on this day R1 reported not having any issues with incontinent care, maintenance of their equipment, and cleanliness of their room and bathroom. Additionally, during the investigation it was learned the facility was in communication with R1's responsible party. At this time, their are no issues with communication.

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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20221128085851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/22/2023

NARRATIVE

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LPA Martinez visited the facility various days at various times. It was learned seven out of eleven residents reported having no issues with the incontinent care that is being provided by facility care staff. Four out of eleven residents reported having issues with timely incontinent care. Additionally, six out of ten residents reported not having any issues with meal service. It was learned four out of six residents reported having issues with meals being served in a timely manner. Due to there not being sufficient evidence, the allegations are unsubstantiated.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

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

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
11/28/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221128085851

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:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff restroom is locked.

INVESTIGATION FINDINGS:

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On 06/22/2023 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez 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, LPA Martinez conducted interviews and tours of the facility. LPA Martinez also toured the staff break room and staff restrooms, and break room and staff bathrooms were unlocked and accessible. Furthermore, restrooms designated for third party medical professional are located at the front of the building and operable. In addition, Title 22 Regulations does not include a staff restroom regulation.

This agency has investigated the complaint alleging (Staff restroom is locked.). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the facility.

Unfounded

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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3