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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 10/09/2023
Date Signed: 10/09/2023 01:10:00 PM


Document Has Been Signed on 10/09/2023 01:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:BROOKDALE LODIFACILITY NUMBER:
397003771
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2220 W. KETTLEMAN LANETELEPHONE:
(209) 367-8870
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:82CENSUS: 73DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mary Margaret Chappell - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required annual inspection visit. LPA met with Administrator and explained purpose of visit. Administrator's Certification expires .

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV areas, and outside yard of the facility to ensure compliance with Title 22 regulations. Food supply is adequate for two day perishable and seven day nonperishable.

Fire extinguishers were last inspected May 17, 2023. Smoke alarms were tested and are operational. The facility has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109.7 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA confirmed all staff present is background cleared.

LPA reviewed four staff and five resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA received the following updated documents: LIC 308 Designation of Administrative Responsibility, and copy of current Administrator’s Certificate.

Exit interview conducted with Administrator. A copy of report and LIC 811 (Confidential Names) left at facility
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
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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