397003771-10-21-2022-27-AS-LKIG-CL8UN7-20221116144329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:31:04 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
08/03/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20220803130753

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: 68	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Mary Margaret Chappel		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained falls while in care
Staff did not administer resident's medication as prescribed

INVESTIGATION FINDINGS:

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On 10-21-22 at 1:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the allegations noted above. LPA met with Administrator Mary Margaret Chappell and explained the purpose of the visit. LPA also conducted interviews with Administrator and Staff1 (S1) during today's visit and reviewed needs and service plan for Resident1 (R1), staffing records, medication records, emergency pendant response log, and facility staff training records.

Allegation #1: Resident sustained falls while in care. LPA conducted staff and resident interviews, and facility file documentation as stated above. Based on record reviews and interviews it was determined that R1 had multiple episodes of attempting to transfer with no evidence of falls as a result. Additionally, based on interviews and record reviews, it was determined that there have been no reported episodes of falls. A review of staffing records reveal staff is present consistently as per scheduled. Additional review of records and interviews reveal R1 has not sustained injuries while in care. {Cont .on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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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Control Number 27-AS-20220803130753

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: 10/21/2022

NARRATIVE

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Based on interviews and record reviews, it is determined that there is not a preponderance of evidence to conclude resident definitively sustained falls while in care. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Staff did not administer resident's medication as prescribed. LPA conducted staff interviews and reviewed medication log sheets and physician's orders for R1. The received allegation states R1 was given the wrong medication. Based on interviews and record reviews, it was determined that R1 had multiple medications changes for a pain medication which appeared on medication log sheets as ordered. It was further determined that facility was consistently following physician's orders as written and correctly transcribing medication to the log sheets on all medication in addition to pain medication. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude that facility was not administering medication as prescribed or giving incorrect medication. As a result, this allegation is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means even though the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Mary Margaret Chappell and a copy of this report was left with Mary.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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