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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 02/14/2022
Date Signed: 02/14/2022 03:40:37 PM


Document Has Been Signed on 02/14/2022 03:40 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: 42DATE:
02/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Brittany Andrews, Associate Executive DirectorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) T. White arrived at the facility on 02/14/2022 unannounced to conduct a case management visit. LPA met with Associate Executive Director, Brittany Andrews and explained the purpose for todays' visit.

LPA amended complaint # 27-AS-20211214154259 dated 12/14/2021 and Associate Executive Director Brittany Andrews signed the amended report. LPA left the amended report at the facility with Associate Executive Director, Brittany Andrews.

Per title 22 no deficiencies being cited during this visit. An exit interview was conducted with Associate Executive Director, Brittany Andrews and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
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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