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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701251
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:39:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2025 and conducted by Evaluator Holly Williams
COMPLAINT CONTROL NUMBER: 27-AS-20250205094444
FACILITY NAME:APPLE RIDGE ASSISTED LIVING, LLCFACILITY NUMBER:
342701251
ADMINISTRATOR:WHITE, CHARLESFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:94CENSUS: 83DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Brandon CollinsTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Unexplained death
Staff did not ensure that a resident's incontinence needs were met
Staff did not observe resident for a change in condition
Staff did not answer resident's call button
INVESTIGATION FINDINGS:
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On 6/5/25 Licensing Program Analysts (LPAs) Holly Williams and Charlie Yang arrived unannounced to deliver findings on this complaint investigation. LPAs met with the Brandon Collins who was briefly interviewed at this time.
The purpose of this visit was to deliver the findings of this investigation to this facility, and it's representative, at this time.

It is alleged that there was an unexplained death at the facility. During the course of the investigation, LPA reviewed records, interviewed Reporting Party (RP), and interviewed staff members. RP stated that R1 had a gash on R1’s forehead and bruising to the side of R1’s eye according to postmortem pictures sent to the LPA. Staff 9 (S9) and S1 in an interview stated that when they found Resident1 (R1) they had fallen out of the chair onto R1’s face Based on the death certificate R1 died of cardiac arrest and other
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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-20250205094444
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: APPLE RIDGE ASSISTED LIVING, LLC
FACILITY NUMBER: 342701251
VISIT DATE: 06/05/2025
NARRATIVE
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health issues that contributed to the death. In 2021 R1 had suffered a stroke and has a history of hypertension. According to record review R1 has several visits to the hospital in 2025. Based on the information, there is not a preponderance of the evidence to substantiate this allegation.

It was alleged that staff did not ensure that a resident's incontinence needs were met. During the course of this investigation, LPA reviewed resident records, interviewed reporting party (RP), and interviewed staff. Based on those interviews and record reviews, LPA discovered that the RP would get to the facility in the morning and there were several times that R1 was laying in their feces and urine. In an interview, with S1 they stated that R1 never complained about not being changed. S1 stated R1 complained about the urinal not being emptied. S1 stated that R1 could transfer from bed to wheelchair by themselves. LPA could not find anyone that had seen R1 laying in R1’s feces or urine. LPA reviewed discharge documents from the hospital, and they do not state R1 had ever had a rash or problems from not being changed. According to interviews no one except for the RP has seen R1 unchanged or laying in R1’s own feces and urine. LPA did find staff that stated that they heard him complain about not being changed but they did not see it. Based on the information, there is not a preponderance of the evidence to substantiate this allegation.

It is alleged that staff did not observe resident for a change of condition. During the course of the investigation, LPA interviewed staff members and the RP. The RP stated that the change of condition was the staff not finding R1 deceased until AM shift. LPA interviewed S1 and S1 stated that S1 saw R1 alive between 3-4 AM and R1 was asking about the internet that was not working at the time and then S1 went back to check on R1 at 5 AM and found R1 deceased. According to S9 they found R1 deceased at 5 AM before the AM shift. Based on the information, there is not a preponderance of the evidence to show that staff did not observe a change in condition.

It was alleged that staff did not answer residents call button. During the course of the investigation, LPA reviewed call logs. On 2/2/2025 the call log says fault and R1 died on 2/4/2025. According to the call logs R1 did not press the call button on the day of his death 2/4/2025 or the day before on 2/3/2025. S14 states that at times when someone’s call button is being reset, or battery is low it can be a fault reading. S14 stated that R1 has had several pendant replacements. Based on the information, there is not a preponderance of the evidence to show staff did not answer resident call button.




SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250205094444
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: APPLE RIDGE ASSISTED LIVING, LLC
FACILITY NUMBER: 342701251
VISIT DATE: 06/05/2025
NARRATIVE
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As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.
There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.

Exit Interview
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3