397003771-12-14-2023-27-AS-LRIS-CYPPFM-20231220101656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:46:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2023 and conducted by Evaluator Renee Campbell

COMPLAINT CONTROL NUMBER: 27-AS-20230920111234

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: 75	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Nicole Bacon, Associate Executive Director		TIME COMPLETED:	12:34 PM

ALLEGATION(S):

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9

Staff mismanage resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced on 12/14/23 at 11:30 AM to deliver complaint findings, LPA Renee Campbell met with Associate Executive Director and explained the purpose of the visit.
Allegation #1: Staff mismanage resident’s medication. When interviewed, H1 stated that hospice had to ask the husband to step out so that staff could directly ask R1 if she wanted pain medication. Per H2, R1 asked for pain medication more “towards the end of her decline”. LPA Campbell observed that the Medication Administration Record (MAR) was completed correctly in regard to the doctor’s orders. S1 also explained how staff ensured R1 gave consent for pain management. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude that the staff mismanaged resident’s medication. Both the doctor’s directives and the clients requests were followed as required.
Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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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