397003771-5-13-2025-27-AS-KHOS-DHRJ2Q-20250618064018

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 05/13/2025
Date Signed: 05/13/2025 06:09:16 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
02/13/2025 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250213113306

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: 74	DATE:	05/13/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	MARY MARGARET CHAPPELL		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are mismanaging residents medication
Staff are not preventing resident from enagaging in inappropriate behaviors

INVESTIGATION FINDINGS:

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On 05/13/2025, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director Nicole Bacon and explained the purpose of today's visit.

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 or that Staff are not preventing resident from engaging in inappropriate behaviors. Both the doctor’s directives and the client’s requests were followed as required. Staff had appropriate training in deescalating behaviors. 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.

An exit interview was conducted, and a copy of this report was given.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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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