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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 01/17/2025
Date Signed: 01/17/2025 11:12:43 AM

Document Has Been Signed on 01/17/2025 11:12 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: 73DATE:
01/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:MARY MARGARET CHAPPELLTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on a incident report that was received 01/06/25. LPA explained purpose of visit to Administrator.

The incident report was regarding a resident's (R1) death. The facility will gather and provide to LPA the care notes from May to January medication administration records for October to January and any incident reports for R1 in the last 12 months. The facility will also provided a copy of R1'S , 602 (Physician's report) and needs and services plan.

This matter is still under investigation.

An exit interview was conducted and a copy of this report was given.
Liza KingTELEPHONE: (650) 676-0442
Kesha LewisTELEPHONE: (916) 764-1024
DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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