397003771-5-19-2021-27-AS-LKIG-C3RPGQ-20210607111842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 05/19/2021
Date Signed: 05/19/2021 04:03:02 PM

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
02/19/2021 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210219094729

FACILITY NAME:	BROOKDALE LODI		FACILITY NUMBER:	397003771
ADMINISTRATOR:	MARY MARGARET CHAPPELL		FACILITY TYPE:	740
ADDRESS:	2220 W. KETTLEMAN LANE		TELEPHONE:	(209) 367-8870
CITY:	LODI	STATE: CA	ZIP CODE:	95242
CAPACITY:	82	CENSUS: 54	DATE:	05/19/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Nicole Bacon, Asst, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility charging additional fees for resident without reappraisal.

Facility charging additional fees for resident without proper notification.

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs conducted a facility visit and met with Assistant Executive Director Nicole Bacon to complete this complaint investigation and deliver findings regarding the allegations listed above.

The investigation consisted of interviews of the Executive Director and also other witnesses including the resident (R-1) identified in the complaint report. LPA requested, obtained and reviewed facility records. The investigation determined that the resident (R-1) was charged for services and those services were included on the service contract. The contact was signed by the resident and subsequently paid on a monthly basis by an insurance company. The disputed fees were reviewed by the facility and the facility agreed to resolve any ongoing dispute by with the insurance complany and resdient. The resident confirmed that he has not had to pay any monthy payments, services fees or any other charges to date. It is noted that the monthly rate has not been increased.

The investigation concluded through interviews and records that there was not sufficient evidence to prove with a preponderance of evidence that the resident (R-1) was charged for services that were not required. For this reason, this allegation is determined to be UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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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