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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 06/16/2021
Date Signed: 06/16/2021 10:11:25 AM

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:BROOKDALE LODIFACILITY NUMBER:
397003771
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2220 W. KETTLEMAN LANETELEPHONE:
(209) 367-8870
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:82CENSUS: 50DATE:
06/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mary Margaret Chappell, Executive DirectorTIME COMPLETED:
10:15 AM
NARRATIVE
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On 06/16/2021, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident report that was submitted to CCLD on 06/01/2021. LPA spoke with Executive Director, Mary Margaret Chappell and explained the purpose of the visit.

Based on incident report, on 5/26/2021 Staff #1 (S1) took a picture of a Resident #1 (R1) in R1’s brief’s while R1 was on the ground from a fall. R1 was unaware of the picture and did not consent to the picture being taken. Management immediately spoke with S1 and suspended S1 immediately. The facility conducted in- service training on 05/27/2021 regarding cell phone use policy and S1 was terminated on 05/26/2021.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview with Administrator. Appeal rights and a copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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: BROOKDALE LODI
FACILITY NUMBER: 397003771
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2021
Section Cited

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87468.1 (a)(1)- Personal Rights of Residents in all facilities.(a)Residents in all residential care facilities for the elderly shall...: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidence by:
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Based on LPA observation, Facility did not comply with the section cited above in 87468.1(a)(1). Based on incident report, S1 took a picture of R1 in his briefs which poses as an immediate health and safety risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021
LIC809 (FAS) - (06/04)
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