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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 12/17/2024
Date Signed: 12/18/2024 08:38:25 AM

Document Has Been Signed on 12/18/2024 08:38 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BROOKDALE LODIFACILITY NUMBER:
397003771
ADMINISTRATOR/
DIRECTOR:		MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2220 W. KETTLEMAN LANETELEPHONE:
(209) 367-8870
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 82TOTAL ENROLLED CHILDREN: 0CENSUS: 78DATE:
12/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:MARY MARGARET CHAPPELLTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 12/22/2024, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit LPA met with ED MARY MARGARET CHAPPELL, and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report that was received by the Department on 10/26/2024.

Current Census was 78.

Based on the incident report received by the department on 10/31/2024, it was reported by this facility that on 10/26/2024 R1 was given the incorrect dose of medication.


Based on interviews conducted it was learned that around the SIR was typed incorrectly and that the dosage given was not as high as first reported to the department. The correct dose was to be 75 MG, first reported was that the dose given was 450 MG, but the actual dose given was 225 MG.

Deficiencies are being cited during todays visit see 809D page....
Liza KingTELEPHONE: (650) 676-0442
Kesha LewisTELEPHONE: (916) 764-1024
DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/18/2024 08:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BROOKDALE LODI
FACILITY NUMBER: 397003771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87465 Incidental Medical and Dental Care
(4) The licensee shall assist residents with administered medications as needed.

This requirement was not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 12/18/2024
Plan of Correction
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Licensee agreed to complete a medication trainging with all staff focusing on rights of adminstration. Kesha.Lewis@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Liza KingTELEPHONE: (650) 676-0442
Kesha LewisTELEPHONE: (916) 764-1024

DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024

LIC809 (FAS) - (06/04)
Page: 2 of 2