397003771-10-21-2022-27-AS-KHOS-CKRLLN-20221101085126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:41:45 PM

Unfounded

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
10/13/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20221013090747

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: 68	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Mary Margaret Chappell		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility is not following COVID-19 guidelines.

INVESTIGATION FINDINGS:

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On 10-21-22 at 3:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation listed above. Allegation states a staff member worked at facility on 10-11-22 while having symptoms of COVID-19. LPA conducted interviews with staff1 (S1) and reviewed COVID-19 line list. LPA also conducted facility tour. Based on interviews and record reviews it was determined that S2 tested positive for COVID-19 on 10/10/22 and S3 tested positive for COVID-19 on 10/7/22. Interviews and record reviews revealed S3 arrived at facility on 10-10-22, tested positive for COVID-19 and was sent home without working at facility. It was further determined that neither S2 or S3 worked on 10-11-22. Additionally, facility has not reported through weekly response testing any additional COVID-19 symptoms or positive results among staff since 10-10-22. A review of staffing records revealed S3 did not work on 10-11-22, and S2 was cleared to work by this date. Facility tour conducted revealed facility has adequate amounts of Personal Protective Equipment (PPE) available for staff use. {Cont. on 9099C}

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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-20221013090747

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: BROOKDALE LODI	FACILITY NUMBER: 397003771
	VISIT DATE: 10/21/2022

NARRATIVE

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Facility tour also revealed staff are practicing COVID-19 precautions including but not limited to wearing face masks, utilizing hand sanitizer, and COVID-19 screening at front entry.

Based on interviews and record reviews, the preponderance of evidence standard is not met, and this allegation is UNFOUNDED. {Cont. 9099C}

No citation issued today.

An exit interview was conducted with Mary Margaret Chappell and a copy of this report was left with Mary.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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