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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 04/28/2023
Date Signed: 04/28/2023 02:34:13 PM


Document Has Been Signed on 04/28/2023 02:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 73DATE:
04/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Margaret Chappell, Exexcutive DirectorTIME COMPLETED:
02:45 PM
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On 04/28/2023, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to the facility to conduct a Case Management due to multiple hospital visits for residents.

R1 experienced a possible unwitnessed fall in Assisted Living on 04/18/2023. Because there were no witnesses, it is not clear if the resident fell. The injury was discovered when she was seen in the dining room eating, with blood running down her leg. R1 was then found to have a laceration. Per S1, when asked, the resident did not know how she had hurt herself. 911 was then called and R1 was taken to the hospital. R1 returned to the facility the same day with care instructions for her cut.

On 04/19/2023 R2 reported vaginal bleeding and requested evaluation. Though she experienced no pain, 911 was called and R2 was taken to the hospital by ambulance. During examination, it was discovered that R2 had a UTI.. She was provided IV antibiotics and discharged the same night with no new orders.

LPA reviewed both client's 602, the facility schedule, IR and the facility fall protocol. Per the documents provided, facility notified the necessary parties and provided medical care in a timely manner.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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