397003771-12-6-2022-27-AS-KHOS-CLWSWL-20221208131432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:28:45 PM

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
11/28/2022 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221128155453

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: 60	DATE:	12/06/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Mary Margaret Chappell - Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced initial ten (10) day complaint investigation visit. LPA explained purpose of visit and discussed with Administrator (AD).

The initial 10-Day visit was conducted on today's date of 12/6/2022. LPA Wallace reviewed facility training records of kitchen and dining room staff. LPA reviewed staff working schedule at facility for approximately the last several months of 2022. LPA Wallace interviewed administrator, kitchen staff, and resident regarding the above allegation.

It was alleged that there was not sufficient food service personnel, training, or working hours scheduled to meet the needs of residents. LPA reviewed all staff schedules, training, and new employees hired after approximately seven staff left employment within a month's time period.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

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 2

Control Number 27-AS-20221128155453

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: 12/06/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 9099 - Page 2

LPA reviewed menus, food handler certificates, orientation training plan for kitchen staff, and observed lunch being served in dining hall. Based on the information provided through interviews and documentation provided to LPA, the allegation that there was not sufficient food service personnel employed, trained and working hours scheduled to meet the needs of residents is deemed UNSUBSTANTIATED.

There was not a preponderance of evidence to prove or disprove that the allegation occurred as reported, therefore the allegation was deemed UNSUBSTANTIATED.

An exit interview was conducted with AD. A copy of this report was provided along with a Confidential Names list, and Appeal Rights.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2