347003117-6-22-2023-27-AS-KHOS-CT9J4E-20230629064300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 06/22/2023
Date Signed: 06/22/2023 09:11:59 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
04/12/2023 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230412133610

FACILITY NAME:	APPLE RIDGE ASSISTED LIVING		FACILITY NUMBER:	347003117
ADMINISTRATOR:	ASHLEY SYLVE		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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9

Illegal Evictions

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 and explained the purpose of today’s visit.

Throughout the course of this investigation, LPA conducted interviews, reviewed facility records, and resident records. LPA reviewed four resident files, and two out of four residents were relocated to a higher level of care facility that would be able to meet the residents need. In addition, ALWP agencies were involved in the relocation process, and the ALWP agencies also assisted with finding a placement for resident 1 and resident 2. Additionally, witness 1 (W1) reported having no issues or concerns about the facility illegally evicting residents. W1 reported R1 had aggressive behaviors, and assisted R1 with finding a new placement that would meet their needs.

Continued...

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)

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Control Number 27-AS-20230412133610

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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Additionally, R2 received placement assistance from their ALWP agency. Moreover, during the investigation, LPA Martinez was informed the relocation of R1 and R2 were a result of a hospitalization, which also resulted in R1 and R2 requiring a higher a higher level of care. Furthermore, throughout the investigation, it was reported facility staff was involved in the process of relocating R1 and R2. It was also learned resident 3 (R3) and resident 4 (R4) were not evicted and continue to resident at this facility.

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

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)

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